hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|GA,"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Evans Memorial Hospital,2024-07-01,2.0.0,Evans Memorial Hospital,"200 North River St Claxton, GA 30417",582257925,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,setting,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,modifiers,standard_charge|Aetna|Commercial|negotiated_dollar,standard_charge|Aetna|Commercial|negotiated_percentage,standard_charge|Aetna|Commercial|negotiated_algorithm,estimated_amount|Aetna|Commercial,standard_charge|Aetna|Commercial|methodology,additional_payer_notes|Aetna|Commercial,standard_charge|Aetna Medicare|HMO|negotiated_dollar,standard_charge|Aetna Medicare|HMO|negotiated_percentage,standard_charge|Aetna Medicare|HMO|negotiated_algorithm,estimated_amount|Aetna Medicare|HMO,standard_charge|Aetna Medicare|HMO|methodology,additional_payer_notes|Aetna Medicare|HMO,standard_charge|Aetna Medicare|POS|negotiated_dollar,standard_charge|Aetna Medicare|POS|negotiated_percentage,standard_charge|Aetna Medicare|POS|negotiated_algorithm,estimated_amount|Aetna Medicare|POS,standard_charge|Aetna Medicare|POS|methodology,additional_payer_notes|Aetna Medicare|POS,standard_charge|Aetna Medicare|PPO|negotiated_dollar,standard_charge|Aetna Medicare|PPO|negotiated_percentage,standard_charge|Aetna Medicare|PPO|negotiated_algorithm,estimated_amount|Aetna Medicare|PPO,standard_charge|Aetna Medicare|PPO|methodology,additional_payer_notes|Aetna Medicare|PPO,standard_charge|Ambetter|Commercial|negotiated_dollar,standard_charge|Ambetter|Commercial|negotiated_percentage,standard_charge|Ambetter|Commercial|negotiated_algorithm,estimated_amount|Ambetter|Commercial,standard_charge|Ambetter|Commercial|methodology,additional_payer_notes|Ambetter|Commercial,standard_charge|Amerigroup|Medicaid|negotiated_dollar,standard_charge|Amerigroup|Medicaid|negotiated_percentage,standard_charge|Amerigroup|Medicaid|negotiated_algorithm,estimated_amount|Amerigroup|Medicaid,standard_charge|Amerigroup|Medicaid|methodology,additional_payer_notes|Amerigroup|Medicaid,standard_charge|BCBS|HMO|negotiated_dollar,standard_charge|BCBS|HMO|negotiated_percentage,standard_charge|BCBS|HMO|negotiated_algorithm,estimated_amount|BCBS|HMO,standard_charge|BCBS|HMO|methodology,additional_payer_notes|BCBS|HMO,standard_charge|BCBS|Open Access|negotiated_dollar,standard_charge|BCBS|Open Access|negotiated_percentage,standard_charge|BCBS|Open Access|negotiated_algorithm,estimated_amount|BCBS|Open Access,standard_charge|BCBS|Open Access|methodology,additional_payer_notes|BCBS|Open Access,standard_charge|BCBS|Pathway|negotiated_dollar,standard_charge|BCBS|Pathway|negotiated_percentage,standard_charge|BCBS|Pathway|negotiated_algorithm,estimated_amount|BCBS|Pathway,standard_charge|BCBS|Pathway|methodology,additional_payer_notes|BCBS|Pathway,standard_charge|BCBS|PPO|negotiated_dollar,standard_charge|BCBS|PPO|negotiated_percentage,standard_charge|BCBS|PPO|negotiated_algorithm,estimated_amount|BCBS|PPO,standard_charge|BCBS|PPO|methodology,additional_payer_notes|BCBS|PPO,standard_charge|CARE IMPROVEMENT PLUS|Medicare|negotiated_dollar,standard_charge|CARE IMPROVEMENT PLUS|Medicare|negotiated_percentage,standard_charge|CARE IMPROVEMENT PLUS|Medicare|negotiated_algorithm,estimated_amount|CARE IMPROVEMENT PLUS|Medicare,standard_charge|CARE IMPROVEMENT PLUS|Medicare|methodology,additional_payer_notes|CARE IMPROVEMENT PLUS|Medicare,standard_charge|CARE NETWORK|Commercial|negotiated_dollar,standard_charge|CARE NETWORK|Commercial|negotiated_percentage,standard_charge|CARE NETWORK|Commercial|negotiated_algorithm,estimated_amount|CARE NETWORK|Commercial,standard_charge|CARE NETWORK|Commercial|methodology,additional_payer_notes|CARE NETWORK|Commercial,standard_charge|Caresource|Medicaid|negotiated_dollar,standard_charge|Caresource|Medicaid|negotiated_percentage,standard_charge|Caresource|Medicaid|negotiated_algorithm,estimated_amount|Caresource|Medicaid,standard_charge|Caresource|Medicaid|methodology,additional_payer_notes|Caresource|Medicaid,standard_charge|Cigna|Commercial|negotiated_dollar,standard_charge|Cigna|Commercial|negotiated_percentage,standard_charge|Cigna|Commercial|negotiated_algorithm,estimated_amount|Cigna|Commercial,standard_charge|Cigna|Commercial|methodology,additional_payer_notes|Cigna|Commercial,standard_charge|Humana Choicecare|Commercial|negotiated_dollar,standard_charge|Humana Choicecare|Commercial|negotiated_percentage,standard_charge|Humana Choicecare|Commercial|negotiated_algorithm,estimated_amount|Humana Choicecare|Commercial,standard_charge|Humana Choicecare|Commercial|methodology,additional_payer_notes|Humana Choicecare|Commercial,standard_charge|Humana Choicecare|Medicare|negotiated_dollar,standard_charge|Humana Choicecare|Medicare|negotiated_percentage,standard_charge|Humana Choicecare|Medicare|negotiated_algorithm,estimated_amount|Humana Choicecare|Medicare,standard_charge|Humana Choicecare|Medicare|methodology,additional_payer_notes|Humana Choicecare|Medicare,standard_charge|Humana Tricare|Commercial|negotiated_dollar,standard_charge|Humana Tricare|Commercial|negotiated_percentage,standard_charge|Humana Tricare|Commercial|negotiated_algorithm,estimated_amount|Humana Tricare|Commercial,standard_charge|Humana Tricare|Commercial|methodology,additional_payer_notes|Humana Tricare|Commercial,standard_charge|IBG|Commercial|negotiated_dollar,standard_charge|IBG|Commercial|negotiated_percentage,standard_charge|IBG|Commercial|negotiated_algorithm,estimated_amount|IBG|Commercial,standard_charge|IBG|Commercial|methodology,additional_payer_notes|IBG|Commercial,standard_charge|Medicaid|Medicaid|negotiated_dollar,standard_charge|Medicaid|Medicaid|negotiated_percentage,standard_charge|Medicaid|Medicaid|negotiated_algorithm,estimated_amount|Medicaid|Medicaid,standard_charge|Medicaid|Medicaid|methodology,additional_payer_notes|Medicaid|Medicaid,standard_charge|Medicare|Medicare|negotiated_dollar,standard_charge|Medicare|Medicare|negotiated_percentage,standard_charge|Medicare|Medicare|negotiated_algorithm,estimated_amount|Medicare|Medicare,standard_charge|Medicare|Medicare|methodology,additional_payer_notes|Medicare|Medicare,standard_charge|Peachstate|Medicare|negotiated_dollar,standard_charge|Peachstate|Medicare|negotiated_percentage,standard_charge|Peachstate|Medicare|negotiated_algorithm,estimated_amount|Peachstate|Medicare,standard_charge|Peachstate|Medicare|methodology,additional_payer_notes|Peachstate|Medicare,standard_charge|UHC|Commercial|negotiated_dollar,standard_charge|UHC|Commercial|negotiated_percentage,standard_charge|UHC|Commercial|negotiated_algorithm,estimated_amount|UHC|Commercial,standard_charge|UHC|Commercial|methodology,additional_payer_notes|UHC|Commercial,standard_charge|VACCN|Medicare|negotiated_dollar,standard_charge|VACCN|Medicare|negotiated_percentage,standard_charge|VACCN|Medicare|negotiated_algorithm,estimated_amount|VACCN|Medicare,standard_charge|VACCN|Medicare|methodology,additional_payer_notes|VACCN|Medicare,standard_charge|min,standard_charge|max,additional_generic_notes
CASIRIVIMAB/IMDEVIMAB 600MG/600MG VIAL,2610135,CDM,636,RC,Q0243,HCPCS,Both,,,0.01,0.01,,0.01,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,0.01,90,,,percent of total billed charges,90% of total billed charges,,35,,,percent of total billed charges,Not reimbursable per contract,0.01,68.7,,,percent of total billed charges,68.7% of total billed charges,0.01,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,0.01,58,,,percent of total billed charges,58% of total billed charges,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,0.01,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,0.01,
SOTROVIMAB 500MG/8ML VIAL,2610146,CDM,636,RC,,,Both,,,0.01,0.01,,0.01,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,0.01,90,,,percent of total billed charges,90% of total billed charges,,35,,,percent of total billed charges,Not reimbursable per contract,0.01,68.7,,,percent of total billed charges,68.7% of total billed charges,0.01,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,0.01,58,,,percent of total billed charges,58% of total billed charges,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,0.01,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,0.01,
TYLENOL (ACETAMINOPHEN) TAB 500MG,2606002,CDM,637,RC,,,Outpatient,,,5,4,,4.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,4.5,90,,,percent of total billed charges,90% of total billed charges,1.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3.44,68.7,,,percent of total billed charges,68.7% of total billed charges,4,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,2.9,58,,,percent of total billed charges,58% of total billed charges,1.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1.02,4.5,
BAMLANIVIMAB 700MG/20ML VIAL,2610123,CDM,636,RC,Q0239,HCPCS,Both,,,5,4,,4.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.5,90,,,percent of total billed charges,90% of total billed charges,1.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3.44,68.7,,,percent of total billed charges,68.7% of total billed charges,4,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,2.9,58,,,percent of total billed charges,58% of total billed charges,1.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1.02,4.5,
MELATONIN CAP 10MG,2610137,CDM,637,RC,,,Outpatient,,,5,4,,4.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,4.5,90,,,percent of total billed charges,90% of total billed charges,1.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3.44,68.7,,,percent of total billed charges,68.7% of total billed charges,4,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,2.9,58,,,percent of total billed charges,58% of total billed charges,1.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1.02,4.5,
SODIUM CHLORIDE NEB SOL 3%/4ML,2610138,CDM,250,RC,,,Outpatient,,,5,4,,4.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,4.5,90,,,percent of total billed charges,90% of total billed charges,1.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3.44,68.7,,,percent of total billed charges,68.7% of total billed charges,4,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,2.9,58,,,percent of total billed charges,58% of total billed charges,1.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1.02,4.5,
"VITAMIN D3 TAB 5,000 IU",2610139,CDM,637,RC,,,Outpatient,,,5,4,,4.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,4.5,90,,,percent of total billed charges,90% of total billed charges,1.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3.44,68.7,,,percent of total billed charges,68.7% of total billed charges,4,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,2.9,58,,,percent of total billed charges,58% of total billed charges,1.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1.02,4.5,
NOVOLIN R (INSULIN HUMAN-R) INJ : 1DOSE,2660016,CDM,637,RC,J1815,HCPCS,Outpatient,,,5,4,,4.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,0.59,120.37,,,fee schedule,120.37% of custom fee schedule,2.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,4.5,90,,,percent of total billed charges,90% of total billed charges,0.61,125.18,,,fee schedule,125.18% of custom fee schedule,3.44,68.7,,,percent of total billed charges,68.7% of total billed charges,4,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,2.9,58,,,percent of total billed charges,58% of total billed charges,0.59,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.59,4.5,
HUMALOG 75/25 (INSULIN MIX) 1 DOSE,2600016,CDM,636,RC,,,Both,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
MIDRIN (ISOMETH/DICHLOR/APAP) CAP,2600029,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
PAMELOR (NORTRIPTYLINE HCL) CAP 10MG,2600056,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
POTASSIUM CHLORIDE (K-DUR) TAB 20MEQ,2600058,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ZESTRIL (LISINOPRIL) TAB 5MG,2600068,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
VASOTEC (ENALAPRIL MALEATE) TAB 5MG,2600069,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ZAROXOLYN (METOLAZONE) TAB 2.5MG,2600090,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
DICLOXACILLIN 250MG CAPSULE,2600116,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
MORPHINE 10MG/5ML UNIT DOSE CUP,2600131,CDM,637,RC,J2270,HCPCS,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.57,120.37,,,fee schedule,120.37% of custom fee schedule,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.72,125.18,,,fee schedule,125.18% of custom fee schedule,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,3.57,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.5,9,
ERY-TAB (ERYTHROMYCIN) BASE TAB 250MG,2600144,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
APRESOLINE(HYDRALAZINE) 10MG,2600145,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
TIGAN (TRIMETHOBENZAMIDE) SUPP 200MG,2600213,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
TIGAN (TRIMETHOBENZAMIDE) SUPP 100MG,2600214,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
NEOSPORIN (NEOMYCIN/BACI/POLY B) OINT,2600324,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ERYTHROMYCIN OPHT OINT 1GM,2600329,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
DEPAKOTE (DIVALPROEX) 250MG TAB,2600414,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
PHENOBARB (PHENOBARBITAL) ELX 20MG/5ML,2600616,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ERYTHROMYCIN SUSP 400MG,2600716,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
CASCARA ORAL SOLUTION : 5ML,2600809,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
DONNATAL (PHENOBARB/BELLADONNA) ELX 5ML,2600876,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
THERAGRAN (MULTIVITAMIN) LIQ 5ML,2600880,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ZOVIRAX (ACYCLOVIR) LIQ 200MG/5ML,2601051,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
BENTYL (DICYCLOMINE HCL) TAB 20MG,2601270,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
PROVERA (MEDROXYPROGESTERONE) TAB 10MG,2601291,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
VENOFER (IRON SUCROSE) 200MG/10ML VIAL,2601328,CDM,636,RC,J1756,HCPCS,Both,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.24,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,0.25,125.18,,,fee schedule,125.18% of custom fee schedule,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,0.24,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.24,9,
INJECTAFER 750MG/15ML VIAL,2601330,CDM,636,RC,J1439,HCPCS,Both,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,1.12,100,,,fee schedule,Pays 100% Medicare OPPS,1.12,100,,,fee schedule,Pays 100% Medicare OPPS,1.12,100,,,fee schedule,Pays 100% Medicare OPPS,1.45,130,,,fee schedule,Pays 130% Medicare OPPS,1.37,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1.14,102,,,fee schedule,Pays 102% Medicare OPPS,9,90,,,percent of total billed charges,90% of total billed charges,1.43,125.18,,,fee schedule,125.18% of custom fee schedule,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,1.12,100,,,fee schedule,Pays 100% Medicare OPPS,1.02,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,1.37,120.37,,,fee schedule,120.37% of custom fee schedule,1.12,100,,,fee schedule,Pays 100% Medicare OPPS,1.45,130,,,fee schedule,Pays 130% Medicare OPPS,8.5,85,,,percent of total billed charges,85% of total billed charges,1.12,100,,,fee schedule,Pays 100% Medicare OPPS,1.02,9,
LANOXICAP (DIGOXIN) CAP 0.1MG,2601342,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ROBAXIN (METHOCARBAMOL) TAB 750MG,2601346,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
MEPERGAN FORTIS (MEPERIDINE/PROMETH) CAP,2602004,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
RITALIN (METHYLPHENIDATE HCL) TAB 5MG,2602008,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
SECONAL (SECOBARBITAL) CAP 100MG,2602011,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
CHLORAL HYDRATE LIQ : 500MG/5ML,2602104,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
DALMANE (FLURAZEPAM HCL) CAP : 15MG,2602107,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
DARVOCET-N-100(PROPOXY/ACE)100/650MG TAB,2602109,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
DARVON 65 (PROPOXYPHENE HCL) CAP : 65MG,2602111,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
VICOPROFEN 7.5 (HYDROCODONE/IBUPROFEN),2602118,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
LIBRIUM (CHLORDIAZEPOXIDE HCL) CAP 5MG,2602122,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
LIBRIUM (CHLORDIAZEPOXIDE HCL)CAP 10MG,2602123,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
LIBRIUM (CHLORDIAZEPOXIDE HCL) CAP 25MG,2602124,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
RESTORIL (TEMAZEPAM) CAP 30MG,2602135,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
TALWIN NX (PENTAZOCINE/NALOXONE)TAB 50MG,2602140,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
XANAX (ALPRAZOLAM) TAB : 0.5MG,2602151,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
EQUANIL (MEPROBAMATE) TAB : 400MG,2602167,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
PENICILLIN VK TAB 250MG,2602213,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
CLINORIL (SULINDAC) TAB : 150MG,2602214,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
LODINE (ETODOLAC) CAP 300MG,2602216,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
TYLENOL (ACETAMINOPHEN) TAB 325MG,2602223,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ZIAC (BISOPROLOL FUM/HCTZ) TAB 2.5MG,2602242,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
SINEQUAN (DOXEPIN HCL) CAP 10MG,2602244,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
INDERAL (PROPRANOLOL HCL) TAB 10MG,2602247,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
INDERAL (PROPRANOLOL HCL) TAB 40MG,2602248,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ISORDIL SR(ISOSORBIDE DINITRATE)TAB 40MG,2602250,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
DO NOT USE,2602252,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
FLUMADINE (RIMANTADINE HCL) TAB 100MG,2602272,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
OXCARBAZEPINE (TRILEPTAL) TAB 300MG,2602274,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ERYC (ERYTHROMYCIN) E.R. CAP 250MG,2602280,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
NIFEREX (IRON COMPLEX) LIQ 100MG,2602282,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
FLUVOXAMINE (LUVOX) TAB 100MG,2602284,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
VOSPIRE (ALBUTEROL E.R.) TAB 4MG,2602285,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
BIAXIN (CLARITHROMYCIN) TAB 250MG,2602312,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
TETRACYCLINE CAP : 250MG,2602325,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
DISALCID (SALSALATE) TAB 500MG,2602506,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
APRESOLINE (HYDRALAZINE HCL) TAB : 50MG,2602514,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ASPIRIN TAB 325MG,2602518,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ASPIRIN CHEWABLE TAB 81MG,2602520,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ASPIRIN EC TAB 325MG,2602521,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ASPIRIN EC TAB 81MG,2602522,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
BENTYL (DICYCLOMINE HCL) LIQ 10MG/5ML,2602533,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
CEPASTAT (PHENOL) LOZENGE : BOX,2602553,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
CLARITIN-D 12HR (LORATADINE/PSE) TAB,2602558,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
COMPAZINE (PROCHLORPERAZINE ) TAB 5MG,2602573,CDM,637,RC,Q0164,HCPCS,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
DONNATAL (BELLADONNA ALK/PB) TAB,2602608,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ERY-TAB (ERYTHROMYCIN) BASE TAB 500MG,2602633,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
LITHIUM CARBONATE CAP 300MG,2602691,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
PRILOSEC (OMEPRAZOLE) CAPSULE 20MG,2602694,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
LOZOL (INDAPAMIDE) TAB 1.25MG,2602701,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ZOCOR (SIMVASTATIN) TAB 20MG,2602704,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
MEVACOR (LOVASTATIN) TAB 20MG,2602705,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
GLYNASE (GLYBURIDE) TAB 6MG,2602707,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
MELLARIL (THIORIDAZINE HCL) TAB 25MG,2602712,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
MELLARIL (THIORIDAZINE HCL) TAB 15MG,2602713,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
PHAZYME (SIMETHICONE) CAP 180MG,2602727,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
NAVANE (THIOTHIXENE) CAP 1MG,2602735,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
NAVANE (THIOTHIXENE) CAP 5MG,2602737,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,2.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,fee schedule,Pays 90% Medicare OPPS,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
NOLVADEX (TAMOXIFEN CITRATE) TAB 10MG,2602739,CDM,637,RC,S0187,HCPCS,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
NIFEREX FORTE-150 (IRON/B12/FOLIC) CAP,2602740,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
PRECOSE (ACARBOSE) TAB 50MG,2602771,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
PREDNISONE TAB 5MG,2602774,CDM,637,RC,J7506,HCPCS,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
PREMARIN (ESTROGEN CONJ) TAB 0.625MG,2602780,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
WELCHOL (COLESEVELAM) TAB 625MG,2602792,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
QUINAGLUTE (QUINIDINE GLUC) TAB 324MG,2602793,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
QUINAMM (QUININE SULF) TAB 260MG,2602794,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
QUINIDINE SULF TAB 200MG,2602796,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
PROLEX-D (GUAIFEN/PHENYLEPH 600/20) TAB,2602807,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
SYNTHROID (LEVOTHYROXINE) TAB 100MCG,2602830,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
TENORMIN (ATENOLOL) TAB 25MG,2602836,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
THORAZINE (CHLORPROMAZINE) TAB 100MG,2602846,CDM,637,RC,Q0172,HCPCS,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
THYROID TAB : 60MG,2602848,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
TIGAN (TRIMETHOBENZAMIDE) CAP 300MG,2602849,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
TICLID (TICLOPIDINE) TAB 250MG,2602850,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
TRILAFON (PERPHENAZINE) TAB 2MG,2602860,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
PREDNISONE TAB 20MG,2603011,CDM,637,RC,J7506,HCPCS,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
MESCOLOR (CPM/PSE/METHSCOPOLAM) TAB,2603028,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
LEVBID (HYOSCYAMINE ER) TAB 0.375MG,2603031,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ENDAL HD (CPM/PE/HD) LIQ : 5ML,2603033,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ATUSS HD (CPM/PE/HD) LIQ : 5ML,2603035,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ATUSS MS (CPM/PE/HD) LIQ : 5ML,2603036,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
SYNTHROID (LEVOTHYROXINE) TAB 75MCG,2603056,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ATUSS DM (CPM/PE/DM) LIQ : 5ML,2603057,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
IMODIUM (LOPERAMIDE) LIQ 5ML,2603062,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
SYNTHROID (LEVOTHYROXINE) TAB 150MCG,2603068,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
NOVOLIN R (INSULIN HUMAN-R) INJ PER UNIT,2603082,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
IMDUR (ISOSORBIDE MONONITRATE) TAB 60MG,2603083,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
DISALCID (SALSALATE) TAB 750MG,2603084,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
CLINORIL (SULINDAC) TAB : 200MG,2603086,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ASACOL (MESALAMINE) TAB 400MG,2605043,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
TAVIST (CLEMASTINE FUMERATE) TAB 2.68MG,2605060,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
SYNTHROID (LEVOTHYROXINE) TAB 125MCG,2605067,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ACCUPRIL (QUINAPRIL) TAB 5MG,2605069,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
NEOMYCIN TAB 500MG,2605085,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
LANTUS (INSULIN GLARGINE) 100UNITS/1ML,2605089,CDM,637,RC,J1815,HCPCS,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,0.59,120.37,,,fee schedule,120.37% of custom fee schedule,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,0.61,125.18,,,fee schedule,125.18% of custom fee schedule,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,0.59,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.59,9,
RYNATAN (CPM/PENYL TANNATE) LIQ 5ML,2605097,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
DA CHEWAB (CMP/PE/METHSCOP) TAB,2605108,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
CHROMAGEN (IRON/B12/FA/IF) CAP,2605110,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ELDEPRYL (SELEGILINE) TAB : 5MG,2605112,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
CODICLEAR (HYDROCOD/GUAIFENESIN) LIQ:5ML,2605120,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
CYTOTEC (MISOPROSTOL) TAB 100MCG,2605130,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ZANAFLEX (TIZANIDINE) TAB 2MG,2605154,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ESTRATEST (EEMT DS) TAB 1.25/2.5MG,2605156,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ESTRATEST (EEMT HS) TAB 0.625/1.25MG,2605157,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
VOLTAREN (DICLOFENAC SOD) TAB 50MG,2605185,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
VITAMIN E (TOCOPHEROL) CAP 400 UNIT,2606004,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ZYPREXA (OLANZAPINE) TAB 5MG,2610118,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ZYPREXA (OLANZAPINE) TAB 10MG,2610119,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
ABILIFY (ARIPIPRAZOLE) TAB 5MG,2610120,CDM,637,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
BOOST/FIB (ENTERAL FORMULA) GT : 240ML,2620009,CDM,250,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
OSMOLITE (ENTERAL FORMULA) GT : 240ML,2620010,CDM,250,RC,,,Outpatient,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
CT ULTRAVIST 300 mgI/ml 10x100ml VIALS,4200015,CDM,636,RC,Q9967,HCPCS,Both,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
CT ULTRAVIST 300 mgl/ml 10x200ml VIALS,4200016,CDM,636,RC,Q9967,HCPCS,Both,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
CT ULTRAVIST 370mgl/ml 10x100ml VIALS,4200017,CDM,636,RC,Q9967,HCPCS,Both,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
CT ULTRAVIST 240 mgI/ml 10x50ml VIALS,4200018,CDM,636,RC,Q9967,HCPCS,Both,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
CT ULTRAVIST 300 mgI/ml 10x50ml VIALS,4200019,CDM,636,RC,Q9967,HCPCS,Both,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
CT ISOVUE 300 mgI/ml 10x50ml VIALS,4209966,CDM,636,RC,Q9967,HCPCS,Both,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
CT ISOVUE 300 mgI/ml 10x100ml VIALS,4209967,CDM,636,RC,Q9967,HCPCS,Both,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
CT ISOVUE 370 mgI/ml 10x100ml VIALS,4209968,CDM,636,RC,Q9967,HCPCS,Both,,,10,8,,8.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9,90,,,percent of total billed charges,90% of total billed charges,3.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,5.8,58,,,percent of total billed charges,58% of total billed charges,2.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.04,9,
NAMENDA (MEMANTINE) TAB 10MG,260008,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ABILIFY (ARIPIPRAZOLE) TAB 10MG,262512,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
RAZADYNE(GALANTAMINE) 8MG,262513,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
GLUCOPHAGE (METFORMIN) ER TAB 500MG,263057,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
OBSERVATION (DIRECT ADM),400003,CDM,762,RC,99219,HCPCS,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
VENT CIRCUIT SET DUAL LIMB HUD1607,791119,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
K-WIRE KM172-26-62,1570032,CDM,278,RC,,,Both,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 5-0 ETHILON 668G,1570400,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 0 CHROMIC 914H,1570501,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 0 ETHIBOND X412H,1570505,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 0 PROLENE 8454H,1570507,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 0 SILK 678G,1570509,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 0 SILK SA66G,1570510,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 0 VICRYL J946H,1570511,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 0 VICRYL J260H,1570512,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 0 VICRYL J376H,1570513,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 1 PROLENE 8435H,1570519,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 2-0 PROLENE 8685H,1570530,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 2-0 SILK 685H,1570531,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 2-0 SILK A185H,1570532,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 2-0 SILK K833H,1570534,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 2-0 VICRYL J417H,1570539,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 3-0 PLAIN L102G,1570549,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 3-0 SILK 684G,1570552,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 3-0 SILK A184H,1570553,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 3-0 SILK K832H,1570555,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 3-0 VICRYL J316H,1570557,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 3-0 VICRYL J258H,1570559,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 3-0 ETHILON 663G,1570562,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 3-0 PROLENE 8684G,1570563,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 3-0 VICRYL J416H,1570564,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 4-0 ETHILON 1667H,1570569,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 4-0 ETHILON 662G,1570570,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 4-0 VICRYL J415H,1570583,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 4-0 VICRYL J496H,1570585,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 2-0 PLAIN 843H,1570589,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 0 PDSII Z370T,1570592,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 4-0 SILK 683G,1570593,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 3-0 PROLENE 8832H,1570596,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 0 VICRYL J381H,1570601,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 2-0 PROLENE 8433H,1570604,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 2-0 VICRYL J317H,1570606,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 2-0 SILK 1588H,1570607,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 0 SILK 680H,1570608,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 0 SILK K834H,1570609,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 0 SILK SA76G,1570610,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 4-0 CHROMIC U203H,1570613,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 2-0 PROLENE 8623H,1570614,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 2-0 PROLENE 8833H,1570615,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 1 PROLENE 8455H,1570617,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 2-0 VICRYL J339H,1570618,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 0 VICRYL J346H,1570619,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 3-0 VICRYL J305H,1570622,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 3-0 VICRYL J356H,1570624,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 2-0 VICRYL J345H,1570625,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 1 PDSII Z359T,1570626,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 2-0 PROLENE 8411H,1570630,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 2-0 PDS PLUS PDP317H,1570634,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 3-0 PDS PLUS PDP316H,1570635,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 3-0 PDS II Z416H,1570636,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 4-0 PDS PLUS PDP513G,1570637,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 2-0 ETHILON 585H,1570646,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 0 PDSII Z358T,1570653,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 2-0 SILK 685G,1570950,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 5-0 FAST ABSORB SURG GUT 1915G,1570951,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 4-0 VICRYL J496G,1570952,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
UNIVERSAL ANESTHESIA SET 2C9218,1805000,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MASK ANESTHESIA 1025,1805004,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MASK ANESTHESIA 1035,1805005,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MASK ANESTHESIA 1045,1805006,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MASK ANESTHESIA 1055,1805007,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MASK ANESTHESIA 1065,1805008,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MASK ANESTHESIA 1075,1805009,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
METHYLERGONOVINE 0.2MG TABLET,2600003,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
EUCERIN MOISTURIZING CREAM 57GM,2600009,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
FUL-GLO 1MG OPHTHALMIC STRIPS 100'S,2600013,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
AMOXICILLIN UD SUSP 250MG/5ML,2600019,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CARDIZEM (DILTIAZEM) TAB 30MG,2600025,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
LANOXIN (DIGOXIN) TAB 0.125MG,2600028,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MINOXIDIL 2.5MG TABLET,2600031,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ESGIC (ACET/CAFF/BUTALBITAL) TAB,2600033,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRIPLE DYE APPLICATOR TOP,2600039,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DEXAMETHASONE 4MG TABLET,2600047,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ZESTRIL (LISINOPRIL) TAB 10MG,2600067,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CEPACOL (BENZOCAINE) LOZENGE,2600072,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
VASOTEC (ENALAPRIL MALEATE) TAB 10MG,2600075,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PAMELOR (NORTRIPTYLINE HCL) CAP 25MG,2600078,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ATIVAN (LORAZEPAM) TAB 0.5MG,2600081,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
LANOLIN (LANOLIN BREAST OINT) 30GM,2600084,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CORGARD (NADOLOL) 20MG TABLET,2600091,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NITROLINGUAL (NITRO) SPRAY 1 USE,2600093,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DIPHENHYDRAMINE 2% CREAM 28GM,2600103,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NON-FORM $5 TAB,2600105,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
COREG (CARVEDILOL) 12.5MG TABLET,2600108,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CANDESARTAN (ATACAND) 16MG TABLET,2600109,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PLENDIL (FELODIPINE) TAB 2.5MG,2600110,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
LITHIUM CARBONATE 150MG CAPSULE,2600112,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
INDERAL (PROPRANOLOL) TAB 20MG,2600125,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SLO-NIACIN 500MG CR TABLET,2600128,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ROXICODONE (OXYCODONE I.R.) 15MG TABLET,2600130,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ROBITUSSIN AC (GUAIF 100MG/COD 10MG) 5ML,2600132,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CEPHADYN (BUTALBUTAL/APAP) 50/325,2600134,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TAPAZOLE(METHIMAZOLE) 5MG TAB,2600137,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ZINC 50MG TAB,2600138,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRIAVIL(PERH/AMITR)2/25MG TAB,2600139,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ZANAFLEX (TIZANIDINE) TAB 4MG,2600142,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NEURONTIN (GABAPENTIN) CAP 400MG,2600146,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
COLESTIPOL(COLESTID) 1GM,2600147,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
K-PHOS(POT ACID PHOS) 500MG TAB,2600149,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
LOVAZA(OMEGA-3 ETHYL) CAP,2600151,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUDAFED PE (PHENYLEPHRINE HCL) 10MG,2600152,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MICARDIS (TELMISARTAN) TAB 80 MG,2600153,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SALINE (SODIUM CL) NASAL SPRAY 45ML,2600164,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
****OXYCODONE (OXYCODONE) I.R.: 20MG TAB,2600167,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
OXYCODONE (OXYCODONE) I.R. 20MG TAB,2600168,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
AMMONIA INHALANT,2600181,CDM,250,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
FISH OIL (OMEGA-3) 1000MG CAP,2600188,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DULCOLAX (BISACODYL) SUPP 10MG,2600207,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
GLYCERIN (ADULT) SUPP,2600208,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
GLYCERIN (CHILD) SUPP,2600209,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PHENERGAN (PROMETHAZINE) LIQ 6.25MG,2600210,CDM,637,RC,Q0169,HCPCS,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PHENERGAN (PROMETHAZINE) W/ CODEINE LIQ,2600211,CDM,637,RC,Q0169,HCPCS,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TYLENOL (ACETAMINOPHEN) DRP 100MG,2600215,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TYLENOL (ACETAMINOPHEN) SUPP 120MG,2600216,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TYLENOL (ACETAMINOPHEN) SUPP 325MG,2600217,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
FLEET ENEMA (SOD PHOS/SOD BIPHOS) 120ML,2600256,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
FLEET PED ENEMA(SOD PHOS/SOD BIPHO) 60ML,2600257,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
FLEET M.O (MINERAL OIL) ENEMA,2600258,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ERYTHROMYCIN OPHTHALMIC OINT 3.5GM,2600338,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
A&D (VITAMIN A&D) OINTMENT : 5GM,2600402,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CALAMINE (ZINC OXIDE) LOTION,2600406,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CETACAINE (BENZO/TETRACAINE) SPRAY 1 USE,2600410,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NITROGLYCERIN 0.1MG PATCH,2600445,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NITROGLYCERIN 0.2MG PATCH,2600446,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NITROGLYCERIN 0.4MG PATCH,2600447,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ROXICET (OXYCODONE/APAP) LIQ 5ML,2600604,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
LOMOTIL(DIPHENOXYLATE/ATROPINE)LIQ 2.5MG,2600609,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TYLENOL/CODEINE ELIX 120MG/12MG 5ML,2600625,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
BACTRIM (SMZ/TMP) 200MG/40MG SUSP 5ML,2600710,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
BENADRYL(DIPHENHYDRAMINE)LIQ:12.5MG/5ML,2600805,CDM,637,RC,Q0163,HCPCS,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
BENTYL (DICYCLOMINE HCL) CAP 10MG,2600806,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
GI COCKTAIL(MAALOX+LEVSIN) LIQ 30 ML,2600833,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
IPECAC SYRUP ORAL 30ML,2600836,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
LANOXIN (DIGOXIN) TAB 0.25MG,2600841,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
KAOPECTATE (BIS.SUB.SAL.) SUSP 30ML,2600846,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MAALOX (AL/MG HYDROXIDE) SUSP 30ML,2600847,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NF-MAALOX EX (MG/AL OH SIMETH)SUS:30ML,2600848,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MAGNESIUM CITRATE LIQ 300ML,2600849,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MILK OF MAGNESIA LIQ 30ML,2600852,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MINERAL OIL LIQ 30ML,2600853,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
REGLAN (METOCLOPRAMIDE) LIQ 5MG/5ML,2600865,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ROBITUSSIN (GUAIFENESIN) 100MG/5ML,2600868,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ROBITUSSIN DM (GUAIFENESIN/DM) LIQ 10ML,2600869,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ED A-HIST (CPM/PHENYLEPHRINE) LIQ 5ML,2600871,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NOHIST-DM (CPM/DM/PHENYLEPHRINE) LIQ 5ML,2600873,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ELDERTONIC (VITAMIN TONIC) LIQ 15ML,2600882,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TYLENOL (ACETAMINOPHEN) LIQ 160MG,2600885,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TYLENOL (ACETAMINOPHEN) UD LIQ 160MG,2600889,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
XYLOCAINE 2% (LIDOCAINE) VISCOUS 15ML,2600891,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MOTRIN (IBUPROFEN) 100MG/5ML SUSP 5ML,2600892,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ALBUTEROL ORAL SOL 2MG/5ML,2600894,CDM,250,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ATARAX (HYDROXYZINE) LIQ 10MG/5ML,2600898,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DILAUDID (HYDROMORPHONE) TAB 4MG,2601160,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
FLAGYL (METRONIDAZOLE) TAB 250MG,2601170,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
VALIUM (DIAZEPAM) TAB 2MG,2601190,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
BENADRYL (DIPHENHYDRAMINE) TAB 25MG,2601269,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
BRETHINE (TERBUTALINE SULF) TAB 2.5MG,2601273,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DECADRON (DEXAMETHASONE) ELX 0.5MG/5ML,2601285,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DILANTIN (PHENYTOIN SOD) CAP 100MG,2601302,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
GEODON (ZIPRASIDONE) CAP 20MG,2601320,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
LAMICTAL (LAMOTRIGINE) TAB 25MG,2601322,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
LAMICTAL (LAMOTRIGINE) TAB 100MG,2601323,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NAC (N-ACETYL-CYSTEINE) CAP 600MG,2601324,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
IMITREX (SUMATRIPTAN) TAB 50MG,2601335,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ROBAXIN (METHOCARBAMOL) TAB 500MG,2601341,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PHENERGAN (PROMETHAZINE HCL) TAB 25MG,2601371,CDM,637,RC,Q0169,HCPCS,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PHENERGAN (PROMETHAZINE HCL) INJ 25MG,2601372,CDM,636,RC,J2550,HCPCS,Both,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.54,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,3.68,125.18,,,fee schedule,125.18% of custom fee schedule,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.54,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.54,13.5,
VITAMIN B-1 (THIAMINE HCL) TAB 100MG,2601405,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
THORAZINE (CHLORPROMAZINE HCL) TAB 25MG,2601407,CDM,637,RC,Q0172,HCPCS,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MS CONTIN (MORPHINE SULF CR) TAB 15MG,2602005,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PERCOCET (OXYCODONE/APAP) TAB 5MG,2602012,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
OXYCONTIN (OXYCODONE CR) TAB 10MG,2602013,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ATIVAN (LORAZEPAM) TAB 1MG,2602101,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
LORCET-10 (HYDROCODONE/ACET) TAB,2602115,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
LORCET-7.5 (HYDROCODONE/ACET) TAB,2602116,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
LORCET-5/325MG(HYDROCODONE/ACET) TAB,2602117,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
LOMOTIL(DIPHENOXYLATE/ATROPINE)TAB 2.5MG,2602127,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PHENOBARB (PHENOBARBITAL) TAB 32.4MG,2602131,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
RESTORIL (TEMAZEPAM) CAP 15MG,2602134,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRANXENE (CLORAZEPATE DIPOT) TAB 7.5MG,2602142,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TYLENOL #3 TAB : 300MG/30MG,2602145,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
VALIUM (DIAZEPAM) TAB 5MG,2602147,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
XANAX (ALPRAZOLAM) TAB 0.25MG,2602150,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
XANAX (ALPRAZOLAM) TAB 1MG,2602152,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
FLORINEF (FLUDROCORTISONE) TAB 0.1MG,2602200,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MYSOLINE (PRIMIDONE) TAB 50MG,2602201,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
AFRIN (OXYMETAZOLINE HCL) NASAL SPRAY,2602204,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
LEVSIN SL (HYOSCYAMINE) TAB 0.125MG,2602206,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SOD BICARB 10 GRAINS TAB 650MG,2602207,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MAGIC MOUTHWASH LIQ 5ML,2602212,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CARDIZEM (DILTIAZEM CD) CAP 120MG,2602222,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ZANTAC (RANITIDINE) LIQ 150MG/10ML,2602233,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CARDIZEM (DILTIAZEM CD) CAP 180MG,2602237,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CARDIZEM (DILTIAZEM CD) CAP 240MG,2602238,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ACCOLATE (ZAFIRLUKAST) TAB : 20MG,2602240,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
BYSTOLIC (NEBIVOLOL) TAB 10MG,2602241,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ZIAC (BISOPROLOL FUM/HCTZ) TAB 10MG,2602243,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NIFEREX-150 (IRON COMPLEX) CAP,2602245,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
INDERAL LA (PROPRANOLOL HCL) CAP 80MG,2602249,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MYCELEX (CLOTRIMAZOLE) TROCHE 10MG,2602251,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
UNIPHYL (THEOPHYLLINE CR) TAB 400MG,2602253,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TUMS (CALCIUM CARBONATE) CHW TAB 500MG,2602254,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
LASIX (FUROSEMIDE) TAB 40MG,2602257,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DIAMOX(ACETAZOLAMIDE) 250MG TAB,2602259,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CLEOCIN (CLINDAMYCIN HCL) CAP 150MG,2602269,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DEPAKOTE DR (DIVALPROEX DR) TAB 250MG,2602271,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
FIBERCON (POLYCARBOPHIL CALCIUM) TAB,2602281,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ZIAC (BISOPROLOL FUM/HCTZ) TAB 5MG,2602286,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ZYLOPRIM (ALLOPURINOL) TAB 100MG,2602287,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
AMOXICLLIN CAP 250MG,2602300,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
AMOXICILLIN CAP 500MG,2602301,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
BACTRIM DS (TMP/SMZ) 160/800 TAB,2602307,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
BACTRIM SS (SMP/TMP) TAB 80/400MG,2602311,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
BACLOFEN TAB 10MG,2602315,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
KEFLEX (CEPHALEXIN) CAP 250MG,2602318,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
KEFLEX (CEPHALEXIN) CAP 500MG,2602319,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
VIBRATAB (DOXYCYCLINE ) TAB 100MG,2602327,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
BICITRA (ORACIT) SOLUTION 30ML UD,2602340,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
BICITRA (ORACIT) SOLUTION 480ML,2602341,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NF-ALDACTAZIDE TAB 25MG/25MG,2602501,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ALDACTONE (SPIRONOLACTONE) TAB 25MG,2602502,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ANTIVERT (MECLIZINE) TAB : 25MG,2602509,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ADVIL (IBUPROFEN) TAB : 200MG,2602511,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
APRESOLINE (HYDRALAZINE HCL) TAB 25MG,2602513,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ASPIRIN 300MG SUPPOSITORY,2602524,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
BUMEX (BUMETANIDE) TAB 0.5MG,2602539,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NF-BUSPAR (BUSPIRONE HCL) TAB 5MG,2602540,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
BUSPAR (BUSPIRONE) TAB 10MG,2602543,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CAPOTEN (CAPTOPRIL) TAB 25MG,2602546,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CATAPRES (CLONIDINE HCL) TAB 0.1MG,2602549,CDM,637,RC,J0735,HCPCS,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CARDURA (DOXAZOSIN) TAB 1MG,2602550,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CARAFATE (SUCRALFATE) TAB 1GM,2602551,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CARDURA (DOXAZOSIN) TAB 4MG,2602554,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CLARITIN (LORATADINE) TAB 10MG,2602557,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
COGENTIN (BENZTROPINE MESYLATE) TAB 1MG,2602565,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
COLACE (DOCUSATE NA) CAP 100MG,2602567,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
COUMADIN (WARFARIN) TAB 1MG,2602577,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
COUMADIN (WARFARIN) TAB 2MG,2602578,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
COUMADIN (WARFARIN) TAB 2.5MG,2602584,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DANTRIUM (DANTROLENE NA) CAP 25MG,2602585,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DIFLUCAN (FLUCONAZOLE) TAB 100MG,2602594,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DITROPAN (OXYBUTYNIN CHLORIDE) TAB 5MG,2602603,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NF-CORRECTOL (BISACODYL) TAB,2602613,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DULCOLAX (BISACODYL) TAB 5MG,2602614,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DYAZIDE (HCTZ/TRIAMTERENE) CAP,2602616,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ELAVIL (AMITRIPTYLINE HCL) TAB 10MG,2602618,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ELAVIL (AMITRIPTYLINE HCL) TAB 25MG,2602619,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
FEOSOL (FERROUS SULF) TAB 325MG,2602636,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SOMA (CARISOPRODOL) TAB 350MG,2602639,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
FLEXERIL (CYCLOBENZAPRINE) TAB 10MG,2602640,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
FOLIC ACID TAB 1MG,2602641,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
GLUCOTROL (GLIPIZIDE) TAB 5MG,2602643,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
GLUCOTROL (GLIPIZIDE XL) TAB 5MG,2602644,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DIABETA (GLYBURIDE) TAB 5MG,2602645,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
GLYNASE (GLYBURIDE) TAB 3MG,2602646,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
HALDOL (HALOPERIDOL) TAB 1MG,2602647,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
HALDOL (HALOPERIDOL) TAB 5MG,2602648,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
HYDROCHLOROTHIAZIDE TAB 25MG,2602651,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
HYGROTON (CHLORTHALIDONE) TAB 25MG,2602656,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
HYTRIN (TERAZOSIN HCL) CAP 1MG,2602658,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
IMODIUM (LOPERAMIDE HCL) CAP 2MG,2602660,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
HYTRIN (TERAZOSIN HCL) CAP 5MG,2602661,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
INDERAL LA (PROPRANOLOL HCL) CAP 60MG,2602663,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
INDOCIN (INDOMETHACIN) CAP 25MG,2602667,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CALAN SR (VERAPAMIL SR) CAP 180MG,2602672,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CALAN (VERAPAMIL HCL) TAB 80MG,2602673,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CALAN (VERAPAMIL) TAB 120MG,2602674,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ISMO (ISOSORBIDE MONONITRATE) TAB 20MG,2602676,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
IMDUR (ISOSORBIDE MONONITRATE) TAB 30MG,2602677,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ISORDIL (ISOSORBIDE DINITRATE) TAB 10MG,2602678,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CALAN SR (VERAPAMIL SR) TAB 240MG,2602679,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
LACTINEX (LACTOBACILLUS) GRANULES 1PKT,2602684,CDM,250,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DEMADEX (TORSEMIDE) TAB 20MG,2602687,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
LASIX (FUROSEMIDE) TAB 20MG,2602688,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
LIBRAX (CLIDINIUM/CHLORDIAZEPOXIDE) CAP,2602690,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
LOPID (GEMFIBROZIL) TAB 600MG,2602692,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
LOPRESSOR (METOPROLOL TARTRATE) TAB 50MG,2602693,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
LOTENSIN (BENAZEPRIL HCL) TAB 10MG,2602695,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MAGNESIUM OXIDE TAB 400MG,2602697,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MELLARIL (THIORIDAZINE HCL) TAB 10MG,2602702,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ZOCOR (SIMVASTATIN) TAB 10MG,2602703,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
METAMUCIL (PSYLLIUM) SF ORNG PKT,2602706,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MOTRIN (IBUPROFEN) TAB 400MG,2602721,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MOTRIN (IBUPROFEN) TAB 600MG,2602722,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MOBIC (MELOXICAM) TAB 7.5MG,2602723,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DAYPRO (OXAPROZIN) TAB 600MG,2602729,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
RELAFEN (NABUMETONE) TAB 750MG,2602730,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NAPROSYN (NAPROXEN) TAB 250MG,2602731,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
LODINE (ETODOLAC) TAB 400MG,2602732,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NIZORAL (KETOCONAZOLE) TAB 200MG,2602741,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NORVASC (AMLODIPINE) TAB 5MG,2602752,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
OSCAL (OYSTER SHELL CALCIUM) TAB 500MG,2602756,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PANCREASE (PANCRELIPASE) CAP,2602757,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NF-PERI-COLACE (DOCUSATE/CASS) LIQ 5ML,2602761,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PEPCID (FAMOTIDINE) TAB 20MG,2602762,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PERI-COLACE (DOCUSATE/SENNA) TAB,2602763,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PERIACTIN (CYPROHEPTADINE HCL) TAB 4MG,2602764,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NF-PEDIAPRED (PREDNISOLONE) LIQ 5MG/5ML,2602765,CDM,637,RC,J7510,HCPCS,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PERSANTINE (DIPYRIDAMOLE) TAB 25MG,2602768,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PREDNISONE TAB 1 MG,2602775,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PREDNISONE TAB 10MG,2602776,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PROCARDIA (NIFEDIPINE) CAP 10MG,2602784,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ADALAT CC (NIFEDIPINE ER) TAB 30MG,2602787,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ADALAT CC (NIFEDIPINE ER) TAB 60MG,2602788,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PYRIDIUM (PHENAZOPYRIDINE) TAB 97.5MG,2602789,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
QUESTRAN (CHOLESTYRAMINE) POWDER 4GM,2602791,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
REGLAN (METOCLOPRAMIDE HCL) TAB 10MG,2602799,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MUCINEX (GUAIFENESIN) TAB 600MG,2602800,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MUCINEX DM (GUAIFENESIN DM) TAB,2602801,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MUCINEX-D (GUAIFEN/PSE 600/60) TAB,2602806,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SINEQUAN (DOXEPIN HCL) CAP 25MG,2602814,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SINEMET (CARBIDOPA/LEVODOPA) 25/100 TAB,2602815,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SINEMET (CARBIDOPA/LEVODOPA) 10/100 TAB,2602816,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NF-POTASSIUM CHLORIDE TAB 8MEQ,2602818,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUDAFED (PSEUDOEPHEDRINE HCL) TAB 30MG,2602823,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SYNTHROID (LEVOTHYROXINE) TAB 50MCG,2602827,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NF-SYNTHROID (LEVOTHYROXINE) TAB 25MCG,2602828,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SYNTHROID (LEVOTHYROXINE) TAB 112MCG,2602829,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TAMBOCOR (FLECAINIDE ACETATE) TAB 50MG,2602832,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TEGRETOL (CARBAMAZEPINE) TAB 200MG,2602834,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TESSALON (BENZONATATE) CAP 100MG,2602835,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TENORMIN (ATENOLOL) TAB 50MG,2602838,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
THEO-DUR (THEOPHYLLINE SA) TAB 300MG,2602839,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
THEO-DUR (THEOPHYLLINE SA) TAB 200MG,2602840,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MULTIVITAMIN TAB,2602841,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PRENATAL (PRENATAL VITAMIN) TAB,2602842,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TORADOL (KETORALAC) TAB 10MG,2602855,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRENTAL (PENTOXIFYLLINE) TAB 400MG,2602857,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TYLENOL (ACETAMINOPHEN) SUPP 650MG,2602863,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DESYREL (TRAZODONE HCL) TAB 50MG,2602865,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
URISPAS (FLAVOXATE HCL) TAB 100MG,2602867,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ULTRAM (TRAMADOL) TAB 50MG,2602868,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
VISTARIL (HYDROXYZINE PAMOATE) CAP 25MG,2602873,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NF-ZANTAC (RANITIDINE) TAB : 150MG,2602878,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ZAROXOLYN (METOLAZONE) TAB 5MG,2602879,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ZYLOPRIM (ALLOPURINOL) TAB 300MG,2602882,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PRELONE SYRUP 15MG/5ML,2603001,CDM,637,RC,J7510,HCPCS,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NORMODYNE (LABETALOL HCL) TAB 100MG,2603012,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
LEVSIN (HYOSCYAMINE) 0.125MG/5ML ELIXIR,2603014,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
VASELINE (PETROLEUM JELLY) PKT OINT,2603022,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
GLUCOTROL (GLIPIZIDE XL) TAB 10MG,2603026,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NF-BUSPAR (BUSPIRONE HCL) TAB 10MG,2603027,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ISONIAZID TAB 300MG,2603029,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NF-ATUSS G (GUAIFENESIN/PE/HD) 5ML,2603037,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NF-ATUSS EX (GUAICOSULFATE/HD) SYRUP 5ML,2603039,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
AMARYL (GLIMEPIRIDE) TAB 2MG,2603043,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NF-MYSOLINE (PRIMIDONE) TAB : 250MG,2603045,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
GLUCOPHAGE (METFORMIN) TAB 500MG,2603050,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
KLONOPIN (CLONAZEPAM) TAB 0.5MG,2603054,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NEURONTIN (GABAPENTIN) CAP 100MG,2603058,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
KLONOPIN (CLONAZEPAM) ODT 0.25MG,2603059,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MYLICON (SIMETHICONE) CHEW TAB 80MG,2603061,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
BUMEX (BUMETANIDE) TAB 1MG,2603063,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TOPROL XL (METOPROLOL SUCC) TAB 50MG,2603064,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
FEROSUL (FERROUS SULF) LIQ 220MG,2603065,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SENOKOT (SENNA) TAB,2603066,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ROXANOL (MORPHINE SULF) CONC LIQ 20MG,2603072,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PEPTO-BISMOL (BISMUTH SUBSALIC)SUSP 30ML,2603073,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PRANDIN (REPAGLINIDE) TAB 1MG,2603074,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DIOVAN (VALSARTAN) TAB 160MG,2603075,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
COLACE (DOCUSATE) SYRUP 20MG/5ML,2603076,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TYLENOL (ACETAMINOPHEN) UD LIQ 325MG,2603085,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NF-PYRIDIUM (PHENAZOPYRIDINE) TAB 200MG,2603089,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DETROL (TOLTERODINE TART) TAB 1MG,2605006,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PLAQUENIL (HYDROXYCHLOROQUINE)TAB 200MG,2605008,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SILVER NIT. STICK TOP,2605011,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SORBITOL 70% LIQ 30ML,2605019,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NYSTATIN LIQ 5ML,2605024,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MS CONTIN (MORPHINE SULF CR) TAB 30MG,2605028,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
AVAPRO (IRBESARTAN) TAB 150MG,2605040,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
AZULFADINE (SULFASALAZINE E.C. TAB 500MG,2605042,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
AVANDIA (ROSIGLITAZONE) TAB : 2MG,2605050,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
OXYCODONE (OXYCODONE IR) TAB 5MG,2605051,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
BACITRACIN OINTMENT PACKETS,2605057,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
GLUCOPHAGE (METFORMIN) TAB 850MG,2605058,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
COUMADIN (WARFARIN) TAB 5MG,2605059,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MEGACE (MEGESTROL ACET) TAB 40MG,2605068,CDM,637,RC,S0179,HCPCS,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ALLEGRA (FEXOFENADINE) TAB 180MG,2605071,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ZYPREXA (OLANZAPINE) TAB 2.5MG,2605074,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PHOS-LO (CALCIUM ACETATE) CAP 667MG,2605079,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NITROSTAT (NITRO) SL TAB USE 0.4MG,2605087,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ALDOMET (METHYLDOPA) TAB 250MG,2605088,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ACCUPRIL (QUINAPRIL) TAB 20MG,2605093,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NITROL (NITROGLYCERIN) PKT OINT,2605102,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
RYTHMOL (PROPAFENONE) TAB 150MG,2605104,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PYRAZINAMIDE TABLET 500MG,2605105,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NEURONTIN (GABAPENTIN) CAP 300MG,2605107,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DEPAKOTE SPRINKLE(DIVALPROEX) CAP 125MG,2605111,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
FIORINAL #3 (ASA/CAF/BUTAL/COD) CAP,2605119,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
FIORICET #3 (ACET/CAF/BUTAL/COD) CAP,2605121,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
METHADONE TAB 10MG,2605135,CDM,637,RC,S0109,HCPCS,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PRAVACHOL (PRAVASTATIN) TAB 20MG,2605138,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PLETAL (CILOSTAZOL) TAB 100MG,2605148,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SWEET-EASE (SUCROSE) SOLUTION : 11ML,2605151,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ALTACE (RAMIPRIL) CAP 2.5MG,2605152,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MICROZIDE(HYDROCHLOROTHIAZIDE)CAP 12.5MG,2605155,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
VITAMIN B6 (PYRIDOXINE HCL) TAB 50MG,2605161,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
BUTISOL (BUTABARBITAL) TAB 30MG,2605164,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ZOFRAN (ONDANSETRON HCL) TAB 4MG ODT,2605167,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NEUTRAPHOS PACKET,2605168,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MIRALAX PAK (PEG 3350 U.D.) PWD 17GM,2605176,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
WELLBUTRIN SR (BUPROPION) TAB 100MG,2605179,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
VOLTAREN (DICLOFENAC SOD) TAB 75MG,2605186,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NF-SUDAL 60/500 (PSE/GUAIFENESIN) TAB,2606001,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
VITAMIN C (ASCORBIC ACID) TAB 500MG,2606003,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
POTASSIUM CHLORIDE (K-DUR) TAB 10MEQ,2610113,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CYSTO/BLADDER IRRIGATION SET,2610531,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
LEVETIRACETAM (KEPPRA) SOLN 500MG/5ML,2611011,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
IV CATH. 24 X 3/4,2613074,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PLATELET IV SET,2613079,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
IV CATH INTROCAN SAFETY 18 X 1-1/4 42545,2613081,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
IV CATH INTROCAN SAFETY 20 X 1 425454602,2613082,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
IV CATH INTROCAN SAFETY 22 X 1 425451102,2613083,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
IV CATH INTROCAN SAFETY 24G X 0.55,2613084,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
IV CATH. 14 X 1.25,2613086,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NF-DELIVER 2 (ENTERAL FORMULA) GT 240ML,2620002,CDM,250,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CALCITRIOL 0.25MCG CAP,2625161,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SYNTHROID (LEVOTHYROXINE) TAB 88MCG,2660001,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DEPAKENE (VALPROIC ACID) LIQ 250MG/5ML,2660004,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
RISPERDAL (RISPERIDONE) TAB 1MG,2660013,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ZANTAC (RANITIDINE) TAB 75MG,2662787,CDM,637,RC,A9270,HCPCS,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SODIUM CHLORIDE TABLET 1000MG,2699995,CDM,637,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
FSBS (FINGER STICK BLOOD SUGAR) : 1EA,2699999,CDM,250,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
OPTIRAY 200-249 MH/ML,4000033,CDM,636,RC,Q9966,HCPCS,Both,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
XR OPTIRAY (ULTRAVIST 240 mgI) HYSTERIO,4000035,CDM,636,RC,Q9966,HCPCS,Both,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
OMNIPAQUE 200-249 MH/ML,4000038,CDM,636,RC,Q9966,HCPCS,Both,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CT OMNIPAQUE PER ML LOW OSMOLAR,4200014,CDM,636,RC,Q9967,HCPCS,Both,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
........O2 HUMIDIFIER PREFILLED 00340,5550001,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
.....CANNULA CURVED NASAL,5550002,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NEBULIZER MICRO-MIST TUBING 1884 HUDSON,5550003,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
EXERCISER VOLUM VOLDYNE 5000 ML IS,5550005,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
.........STERILE WATER 340 ML,5550006,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TENT FACE W/TUBING,5550007,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
......CANNULA CURVED NASAL TIP,5550009,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
....NEBULIZER MICRO-MIST TUBING RSP04726,5550012,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
O2 NEBULIZER LARGE VOLUME 1770,5550016,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TUBING CORRUGATED 001410,5550019,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
.........AEROSOL MASK PEDIATRIC 1085,5550020,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MUCOUS TRAP 406,5550021,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
......WATER DIST (1 GAL) RESP,5550023,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
........AEROSOL DRAINAGE SYSTEM W/WYE,5550035,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
....O2 HUMIDIFIER PREFILLED 500ML 002620,5550036,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NEBULIZER MISTY MAX 002446,5550037,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
EXERCISER VOLUM AIRLIFE 4000ML 001902A,5550038,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
AEROSOL MASK PEDIATRIC 001263,5550041,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
........O2 HUMIDIFIER PREFILLED RHP340U,5550044,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
........O2 HUMIDIFIER PREFILLED RHP340U,5550050,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
MUCOUS TRAP MST4000 40CC,5550052,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
EXERCISER COACH 2 2500ML,5550053,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
EXERCISER VOLUM AIRLIFE 2500ML 001903A,5550054,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUCTION CATH KIT 12 FR. SAFE T VAC 37224,7900012,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUCTION CATH KIT 14 FR. SAFE T VAC 37424,7900014,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CANNULA PED 331 E HOSPITAK,7900331,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
KLING 2 STERILE,7901152,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
KLING 3 STERILE,7901153,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
KLING 4 STERILE,7901154,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
BACTERIAL FILTER 1605 HUDSON,7901605,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CANNULA INFANT 1828 HUDSON,7901828,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CANNULA PED 1838 HUDSON,7901838,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ARM SLING SMALL,7902002,CDM,270,RC,A4565,HCPCS,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ARM SLING MEDIUM,7902003,CDM,270,RC,A4565,HCPCS,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ICE BAG SMALL REFILLABLE W/TIES,7902005,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ICE BAG LARGE REFILLABLE W/TIES,7902006,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
.......NEBULIZER PREFILLED 044-28 HUDSON,7904428,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ARTERIAL BLOOD GAS KIT 4599P 1,7904599,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ABD PAD NON21450,7905001,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ABD PAD 9190A,7905002,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
AMNIHOOK,7905004,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
LEVIN TUBE 14 FR. DYND70484,7905056,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
LEVIN TUBE 16 FR. DYND70486,7905057,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
LEVIN TUBE 18 FR. DYND70488,7905059,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
URINE LEG BAG,7905060,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SALEM SUMP TUBE 18 FR.,7905062,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SALEM SUMP TUBE 16 FR.,7905063,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
IRRIGATION TRAY,7905064,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SALEM SUMP TUBE 12 FR.,7905067,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
COVER/POST-OP SPONGE,7905068,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SALEM SUMP TUBE 14 FR.,7905069,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
IRRIGATION TRAY DYND20102,7905076,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
IRRIGATION TRAY DYND20302 PISTON,7905077,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
IRRIGATION TRAY DYND20300 PISTON,7905078,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DRESSING TELFA 2 X 3,7905103,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DRESSING NON ADHERENT 2 X 3,7905104,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
URINE STRAINER,7905119,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
URINE STRAINER DYND4712,7905120,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ELASTIC BANDAGE 3 MDS055003Z,7905139,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
BAND AID XL 6136LF,7905140,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ELASTIC BANDAGE 6 REB2006,7905141,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ELASTIC BANDAGE 6 MDS055006,7905142,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ELASTIC BANDAGE 4 MDS055004,7905143,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ELASTIC BANDAGE 4 REB2004,7905144,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ELASTIC BANDAGE 4 MDS057004,7905145,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ELASTIC BANDAGE 3 REB2003,7905146,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ARM SLING LARGE,7905154,CDM,270,RC,A4565,HCPCS,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DRESSING NON ADHERENT 3 x 8,7905167,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DRESSING TELFA 3 x 8,7905168,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CATH FOLEY 12 FR. DYND11685P,7905187,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CATH FOLEY 14 FR. DYND11659P,7905191,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CATH TRAY 14 FR.,7905196,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CATH TEXAS,7905198,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CATH FOLEY 12 FR. DYND11752,7905221,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
EAR & ULCER SYRINGE DYND70280,7905230,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
EAR & ULCER SYRINGE 44402,7905231,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
EAR & ULCER SYRINGE 4172,7905232,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SPONGES PEANUT DMA74712,7905233,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SPONGES PEANUT 30-106,7905236,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
STYLET INTUBATING 502507,7905238,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
STYLET INTUBATING 502501,7905239,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
GRADUATE DISP.,7905242,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
GRADUATE DISP. DYND80417,7905243,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
HEEL PROTECTOR MDT829280,7905246,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
HEEL PROTECTOR MDT823280,7905247,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
HEEL PROTECTOR M3014D6,7905249,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
HEEL PROTECTOR 7981007,7905250,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ICE PACK SMALL 11400-100,7905253,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
POLYSKIN DRESSING 2 X 2-3/4,7905254,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DRESSING TRANSPARENT FILM 2.375 X 2.75,7905255,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DRESSING TRANSPARENT SURESITE 123,7905256,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ARM SLING MEDIUM ASL2104,7905259,CDM,270,RC,A4565,HCPCS,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
OP SITE 2 X 3,7905262,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DRESSING TRANSPARENT FILM 4 X 4.75,7905273,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ELASTIC BANDAGE 4 MDS077004Z,7905274,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
OP SITE 5 1/2 X 4IN 4963,7905282,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
OP SITE 5 1/2 X 4,7905283,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
HUGGIES MEDIUM,7905285,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
OB PAD STERILE,7905290,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ELASTIC BANDAGE 6 MDS077006Z,7905306,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SPLINT FINGER 3 1/4 PLN END 7973214,7905314,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SPLINT FINGER 5 1/4 BALL END 7973217,7905315,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
RESTRAINT WRIST/ANKLE 2510,7905316,CDM,274,RC,,,Both,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SPLINT FINGER ALL SZ,7905322,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SPLINT FINGER 3 1/4 BALL END 7973215,7905323,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SPLINT FINGER 4 1/4 BALL END 7973216,7905324,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SPLINT FINGER 6 1/4 BALL END 7973218,7905325,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SPLINT FINGER 7 1/4 BALL END 7973219,7905326,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE REMOVAL KIT,7905328,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SPLINT FINGER 1 1/4 PLN END 7973212,7905329,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SPLINT FINGER 2 1/4 PLN END 7973213,7905330,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE REMOVAL KIT 7160,7905333,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE REMOVAL KIT MDS708550,7905334,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUCTION CANISTER 2500CC 711107,7905343,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
VAGINAL SPEC DISPO VAG1001 (SM),7905392,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
VAGINAL SPEC DISPO VAG1002 (MED),7905393,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
VAGINAL SPEC DISPO VAG1003 (LG),7905394,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
YANKAUER SUCT HANDLE K83A,7905411,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
YANKAUER SUCT HANDLE 6FT DYND50135,7905418,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
YANKAUER SUCT HANDLE 10FT DYND50138,7905419,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CATH PLUG,7905429,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PENROSE TUBING 3/4,7905464,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CATH RED RUBBER ROBINSON 10 FR.,7905483,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
FEED TUBE 5 FR & 8 FR,7905484,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CATH RED RUBBER ROBINSON 14 FR. 660143,7905485,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CATH RED RUBBER 14 FR. DYND13514H,7905488,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ADAPTIC DRG 3 X 3,7905501,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
XEROFORM 1 X 8 CUR253180Z,7905511,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
XEROFORM 5 X 9,7905520,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
XEROFORM 5 X 9 CUR253590,7905521,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
GAUZE FLUFF SPONGE 6 X 6.75 10/TRAY,7905526,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
GAUZE FLUFF SPONGE 6 X 6.75 5/TRAY,7905527,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRACHEAL TUBE 3.0 86234,7905535,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRACHEAL TUBE 4.0 UNCUFFED 86225,7905536,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRACHEAL TUBE 2.5 86222 UNCUFFED,7905538,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRACHEAL TUBE 3.0 86223,7905539,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRACHEAL TUBE 3.0 86442,7905540,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRACHEAL TUBE 5.0 UNCUFFED 86227,7905544,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRACHEAL TUBE 3.5 86224 UNCUFFED,7905546,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRACHEAL TUBE 2.5 86233 UNCUFFED,7905547,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
EYE PAD NON21600Z,7905548,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
EXTENTION TUBE STOPCOCK,7905549,CDM,270,RC,L0120,HCPCS,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRACHEAL TUBE 4.5 UNCUFFED 86226,7905551,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
EYE PAD,7905552,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRACHEAL TUBE 8.0,7905553,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRACHEAL TUBE 7.0,7905554,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRACHEAL TUBE 7.5,7905555,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRACHEAL TUBE 6.5 86110,7905556,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRACHEAL TUBE 4.5 CUFFED 86445,7905557,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRACHEAL TUBE 5.0 86107,7905558,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRACHEAL TUBE 5.5 86108,7905559,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRACHEAL TUBE 3.0 86443,7905560,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRACHEAL TUBE 4.0 CUFFED 86444,7905561,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRACHEAL TUBE 6.0 86109,7905564,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRACHEAL TUBE 8.5,7905566,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRACHEAL TUBE 9.0,7905570,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ELECTRODE CLEAR TRACE 1700-005,7905571,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
VALVE ADULT LOPEZ,7905591,CDM,270,RC,L0120,HCPCS,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PEEP VALVE DISPOSABLE,7905594,CDM,270,RC,L0120,HCPCS,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRACHEAL TUBE 3.5 86235 UNCUFFED,7905598,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUTURE 6-0 ETHILON 660G,7905626,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ELASTIC BANDAGE 2 REB2002,7905666,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ELASTIC BANDAGE 2 MDS055002,7905667,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SURGICAL SUCTION POOLE DYND50172,7905689,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
KLING STERILE 3 STRETCH 2232,7905697,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
KLING STERILE 4 STRETCH 2236,7905698,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
KLING STERILE 6 STRETCH 2238,7905699,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
STERI STRIP 1 X 5 R1548,7905700,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
STERI STRIP 1 X 5 A1848,7905701,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
STERI U-DRAPE 1015,7905703,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CONFORM 4,7905705,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CONFORM 6,7905706,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
KERLIX 4.5 6715,7905707,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
STERI STRIP 1/8 X 3,7905708,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
STERI STRIP 1/2 X 4 R1547,7905709,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CATH SUCTION T60C,7905711,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TUBING NONCONDUCTIVE OR512,7905717,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TUBING NONCONDUCTIVE ST1003,7905719,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TUBING FUNNEL 18IN,7905720,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TUBING CONNECTOR 6FT,7905722,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
K-WIRE KM172-26-45 .045,7905723,CDM,278,RC,,,Both,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
UNDERPAD 30 X 36 EXTRASORB MSC8003003,7905746,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
UNDERPAD 30 X 36 DRY PREMIUM,7905747,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
UNDERPAD EXTRABULK3036,7905748,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
BITE JAWLOCK,7905749,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
AIRWAY NASAL LF 20FR 5075-20,7905750,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
LAP SPONGE 18 X 18 MDS251518LF,7905751,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
AIRWAY NASAL LF 22FR 5075-22,7905754,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
UNDERPAD WINGS QUILTED 30 X 36,7905757,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
BRIEF ADULT,7905760,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
UNDERPAD ULTRASORB EXTRASORB3036A,7905761,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
AIRWAY NASAL LF 26FR 5075-26,7905762,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
AIRWAY NASAL LF 28FR 5075-28,7905763,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
AIRWAY NASAL LF 30FR 5075-30,7905765,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
AIRWAY NASAL LF 32FR 5075-32,7905769,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
AIRWAY NASAL LF 36FR 5075-36,7905772,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
UNDERPAD ULTRASORB EXTSB3036A350,7905788,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
COBAN 4 STERILE,7905793,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
STAPLE REMOVER SKIN DYNJ04058Z,7905846,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
STAPLE REMOVER SKIN DYNJ04059,7905850,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ELECTRODE ECG LL110,7905859,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CATH KIT FEMALE,7905868,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
GROUNDING PAD XODUS 20240,7905869,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
BANDAGE ESMARK 4,7905886,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
BANDAGE ESMARK 6,7905887,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SURGICAL TIP CLEANER,7905918,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
VAGINAL SPECULUM/SHEATH (MED),7905920,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
VAGINAL SPECULUM/LIGHT (SM),7905922,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
COBAN 6 STERILE,7905933,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TOWEL DISPO OR,7905935,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PAD LEG PLATE 2464AAO,7905976,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CATH LEG STRAP,7905988,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CATH LEG STRAP DYND16800,7905989,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CATH ALL PURP A/SZ,7905994,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUCTION CATH KIT 10 FR. SAFE T VAC 37024,7907024,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PULMOGUARD PFT FILTER 29 7950 050,7907950,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRACH CLEANING KIT,7915003,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
WATER DIST (1 GAL),7915426,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
YANKAUER SUCTION YANK1001,7915707,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUCTION CANISTER 1200CC 713004,7915708,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUCTION CANISTER 1200 CC 65651-212,7915709,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
YANKAUER SUCTION K86,7915713,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
YANKAUER SUCTION DYND50130,7915715,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUCTION CANISTER 3000 CC 65651-230,7915716,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUCTION CANISTER 1200 CC 65651-395,7915717,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
SUCTION CANISTER 1200CC PHER1200B,7915722,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CANNULA ADULT 1103 HUDSON,7919101,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
O2 MASK ADULT 1041,7919102,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NON-REBREATHING MASK ADULT 1059,7919104,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CANNULA ADULT 1325 CAREFUSION,7919107,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
O2 MASK ADULT 001201,7919108,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NON-REBREATHING MASK ADULT 001211,7919111,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CANNULA CO2 SAMPLING ADULT 47077725,7919112,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
CANNULA CO2 SAMPLING ADULT,7919114,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
O2 TUBING 001302,7919115,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
VENT CIRCUIT SET STANDARD 1607,7919117,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
VENTURI MASK ADULT 001255,7919155,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
AEROSOL MASK ADULT 001206,7919200,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
AEROSOL MASK ADULT HUD1083,7919201,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
...........FACE TENT W/AEROSOL TUBING,7919202,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRACH MASK 1075 HUDSON,7919203,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TRACH MASK 001225,7919204,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
TUBING CORRUGATED HSK626,7919207,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
FEED TUBE 5 FR 260802,7950000,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
FEED TUBE 5FR 155720,7950001,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
FEED TUBE 5FR 460802,7950002,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PENROSE DRAIN LATEX FREE 1/2 DYND50428,7950005,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PENROSE TUBING 1/4 0912010,7950007,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PENROSE TUBING 1/4,7950014,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
COHESIVE BANDAGE 2,7950017,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
COBAN 2,7950018,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
COFLEX BANDAGE 1.5,7950025,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
COFLEX BANDAGE 2,7950026,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
PENROSE TUBING 3953 1/4,7950037,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NEEDLE SPINAL QUINCKE 405184,7950043,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ELECTRODE FLAT BLADE 6 138107,7950044,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
COHESIVE BANDAGE 3,7950049,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
COLOSTOMY POUCH 401515,7950094,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
COBAN 4,7950130,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
COBAN 3,7950136,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ELECTRODE PED 01148592,7950156,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DRESSING DUODERM HYDROACTIVE GEL 30G,7950158,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
BITE BLOCK ENDO 00712803,7950166,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
BITE BLOCK BLOX ENDO SBT-546-100,7950167,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
BRIEF ADULT XL FITEXTRAXLG,7950172,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
NASAL TUBE FASTENER,7950176,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
BRIEF ADULT XL 66035A,7950178,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DRAIN SPONGE,7950211,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DRAIN SPONGE IV 2 X 2,7950212,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
STAPLE REMOVAL TRAY 772,7950216,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DRAIN SPONGE NON256000,7950218,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
ELASTIC BAND 6 STER. REB3116,7950231,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DEMA WRAP 4IN,7950271,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DEMA WRAP 3IN,7950272,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DEMA WRAP LATEX FREE 2IN,7950273,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DRESSING KENDALL FOAM 4 X 4,7950274,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DRESSING OPTIFOAM 4 X 5,7950278,CDM,272,RC,A6210,HCPCS,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DRESSING OPTIFOAM 3 X 3,7950279,CDM,272,RC,A6209,HCPCS,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
DRESSING OPTIFOAM BORDER 6 X 6,7950292,CDM,270,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
VACUTAINER LUERLOK ACCESS DEVICE,7950341,CDM,272,RC,,,Outpatient,,,15,12,,12.75,85,,,percent of total billed charges,85% of total billed charges,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,3.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,percent of total billed charges,90% of total billed charges,5.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10.31,68.7,,,percent of total billed charges,68.7% of total billed charges,12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13.5,90,,,fee schedule,Pays 90% Medicare OPPS,8.7,58,,,percent of total billed charges,58% of total billed charges,3.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.06,13.5,
BLADE ELECTRODE 165MM,1570829,CDM,272,RC,,,Outpatient,,,18,14.4,,15.3,85,,,percent of total billed charges,85% of total billed charges,4.5,100,,,fee schedule,Pays 100% Medicare OPPS,4.5,100,,,fee schedule,Pays 100% Medicare OPPS,4.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.67,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,10.17,56.5,,,percent of total billed charges,56.5 percent of total billed charges,10.17,56.5,,,percent of total billed charges,56.5 percent of total billed charges,10.17,56.5,,,percent of total billed charges,56.5 percent of total billed charges,10.17,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,16.2,90,,,percent of total billed charges,90% of total billed charges,6.3,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,12.37,68.7,,,percent of total billed charges,68.7% of total billed charges,14.4,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,16.2,90,,,fee schedule,Pays 90% Medicare OPPS,10.44,58,,,percent of total billed charges,58% of total billed charges,3.67,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,15.3,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.67,16.2,
SUTURE 3-0 VICRYL RAPIDE VR497,1570654,CDM,272,RC,,,Outpatient,,,18.74,14.99,,15.93,85,,,percent of total billed charges,85% of total billed charges,4.69,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.82,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,10.59,56.5,,,percent of total billed charges,56.5 percent of total billed charges,10.59,56.5,,,percent of total billed charges,56.5 percent of total billed charges,10.59,56.5,,,percent of total billed charges,56.5 percent of total billed charges,10.59,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,16.87,90,,,percent of total billed charges,90% of total billed charges,6.56,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,12.87,68.7,,,percent of total billed charges,68.7% of total billed charges,14.99,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,16.87,90,,,fee schedule,Pays 90% Medicare OPPS,10.87,58,,,percent of total billed charges,58% of total billed charges,3.82,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,15.93,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.82,16.87,
......MRI GADOLYNIUM PER ML,440024,CDM,255,RC,A9576,HCPCS,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,4.07,18,
SUTURE 0 CHROMIC U246H,1570503,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SUTURE 0 PROLENE 8418H,1570506,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SUTURE 2-0 CHROMIC G123H,1570525,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SUTURE 3-0 CHROMIC 810H,1570543,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SUTURE 3-0 CHROMIC G122H,1570544,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SUTURE 3-0 CHROMIC N877H,1570546,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SUTURE 3-0 ETHILON 1669H,1570547,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SUTURE 4-0 PROLENE 8629H,1570575,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SUTURE 5-0 MONOCRYL Y493G,1570577,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SUTURE 2-0 PLAIN 853H,1570590,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SUTURE 3-0 PROLENE 8663G,1570595,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SUTURE 4-0 POLYSORB SL638,1570602,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SUTURE 3-0 ETHILON 1663G,1570603,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SUTURE 4-0 MONOCRYL Y426H,1570611,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SUTURE 3-0 MONOCRYL Y427H,1570612,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SUTURE 3-0 VICRYL J683H,1570623,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SUTURE 3-0 MONOCRYL MCP416H,1570632,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SUTURE 4-0 MONOCRYL MCP513G,1570633,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SUTURE 3-0 MONOCRYL Y497G,1570641,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SUTURE 4-0 MONOCRYL Y415H,1570642,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SUTURE 4-0 MONOCRYL Y214H,1570648,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SUTURE 3-0 MONOCRYL Y215H,1570649,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
LOOP VESSEL RED MAXI SILICONE,1570650,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
LOOP VESSEL RED MINI SILICONE,1570651,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SUCTION SLEEVE NEPTUNE 165MM,1570808,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
NICOTINE PATCH 7MG,2600006,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
LACRILUBE (ARTIFICIAL TEARS) OPHTH OINT,2600042,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
PAXIL (PAROXETINE HCL) TAB 20MG,2600060,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
REQUIP (ROPINIROLE) 0.5MG TABLET,2600063,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
PROZAC (FLUOXETINE) CAP 10MG,2600066,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
AMPICILLIN INJ 2GM,2600073,CDM,636,RC,J0295,HCPCS,Both,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.17,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,3.29,125.18,,,fee schedule,125.18% of custom fee schedule,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,3.17,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.17,18,
MYCELEX (CLOTRIMAZOLE) 1% CREAM 15GM,2600079,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
ROZEREM (RAMELTEON) 8MG TABLET,2600107,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
TOPAMAX (TOPIRAMATE) TAB 25MG,2600122,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
MIRAPEX 0.5MG TABLET,2600126,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
PEDIALYTE SOLUTION,2600156,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
NEO-SYNEPHRINE 1% (PHENYLEPHRINE) SPRAY,2600161,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
NEO-SYNEPHRINE 0.25%(PHENYLEPHRINE)SPRAY,2600165,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
TUCKS (HAMAMELIS LEAF/GLYCE) PAD,2600267,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
GENTAMICIN 0.1% CRM 15GM,2600422,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
HYDROCORTISONE 1% CREAM,2600425,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
TRIAMCINOLONE 0.1% CRM,2600429,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
MYCOLOG (NYSTATIN/TRIAMCINO) CRM 15GM,2600441,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
MYCOLOG (NYSTATIN/TRIAMCINO) OINT 15GM,2600442,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
NYSTATIN CRM,2600443,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
NICODERM (NICOTINE) PATCH 21MG,2600444,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
LORTAB(HYDROCODONE/ACET) 7.5/15ML,2600614,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
TUSSIONEX (HYDROCODONE/CPM) LIQ 5ML,2600624,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
DILANTIN (PHENYTOIN) LIQ 100MG/4ML,2600818,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
FLEET PHOSPHA SODA LIQ 45ML,2600830,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
TYLENOL PED DROPS 100MG/1ML 15ML,2600888,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
AMPICILLIN INJ 250MG,2601002,CDM,636,RC,,,Both,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
AMPICILLIN INJ 500MG,2601004,CDM,636,RC,,,Both,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
AMPICILLIN INJ 1GM,2601005,CDM,636,RC,J0290,HCPCS,Both,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.91,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,0.95,125.18,,,fee schedule,125.18% of custom fee schedule,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,0.91,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.91,18,
COMPAZINE (PROCHLORPERAZINE) SUPP 25MG,2601282,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
PROSCAR (FINASTERIDE) TAB 5MG,2601432,CDM,637,RC,S0138,HCPCS,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
AVODART (DUTASTERIDE) CAP 0.5MG,2601433,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
PROZAC (FLUOXETINE) CAP 20MG,2602221,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
NF-CARDIZEM (DILTIAZEM CD) CAP 360MG,2602239,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
COREG (CARVEDILOL) 6.25MG TABLET,2602270,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
NYSTATIN OINT,2602275,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
WELLBUTRIN SR (BUPROPION) TAB 150MG,2602279,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
MACROBID (NITROFURANTOIN) CAP 100MG,2602322,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
ZOVIRAX (ACYCLOVIR) TAB 400MG,2602331,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
EFFEXOR XR (VENLAFAXINE) CAP 37.5MG,2602523,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
BUSPAR DIVIDOSE (BUSPIRONE) TAB 15MG,2602544,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
COZAAR (LOSARTAN) TAB 50MG,2602545,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
CARAFATE (SUCRALFATE) LIQ 1GM/10ML,2602547,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
COLCHICINE (COLCRYS) TAB 0.6MG,2602569,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
DILANTIN (PHENYTOIN SOD) 100MG INJ,2602596,CDM,636,RC,J1165,HCPCS,Both,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,0.54,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,0.56,125.18,,,fee schedule,125.18% of custom fee schedule,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,0.54,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.54,18,
HYZAAR (LOSARTAN/HCT) 50-12.5MG TAB,2602653,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
MYLICON (SIMETHICONE) DROPS,2602728,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SYMMETREL (AMANTADINE) CAP 100MG,2602826,CDM,637,RC,G9017,HCPCS,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
ZOLOFT (SERTRALINE HCL) TAB 50MG,2602866,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
XYLOCAINE 2% (LIDOCAINE) VIAL 10ML,2603018,CDM,636,RC,,,Both,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
RIFAMPIN CAPSULE 300MG,2603030,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
CHLORASEPTIC (PHENOL) 1.4% SPRAY,2603032,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
CARDIZEM (DILTIAZEM CD) CAP 300MG,2603044,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
IV CATH. 22 X 1,2603070,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
BACITRACIN EYE OINTMENT 3.5GM,2605000,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
CELEBREX (CELECOXIB) CAP 100MG,2605007,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
LAC-HYDRIN (AMLACTIN) 12% LOTION,2605032,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
ZYRTEC (CETIRIZINE) TAB 10MG,2605039,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
AVANDIA (ROSIGLITAZONE) TAB 4MG,2605041,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
CELEXA (CITALOPRAM HBR) TAB 20MG,2605070,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
NICODERM (NICOTINE) PATCH 14MG,2605076,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
HIBICLENS (CHLORHEXIDINE) 4% SCRUB:120ML,2605081,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
CHRONULAC (LACTULOSE) LIQ 30ML,2605098,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
REMERON (MIRTAZAPINE) TAB 15MG,2605100,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
BETAPACE (SOTALOL) TAB 80MG,2605103,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
GENTAMICIN 0.1% OINT 15GM,2605117,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
RISPERDAL (RISPERIDONE) TAB 1MG,2605123,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
DIOVAN (VALSARTAN) TAB 80MG,2605150,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
LIDOCAINE 2.5%/ PRILOCAINE 2.5% CREAM,2605153,CDM,250,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
CELEBREX (CELECOXIB) CAP 200MG,2605184,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
COMPAZINE (PROCHLORPERAZINE) INJ 10MG,2610121,CDM,636,RC,,,Both,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
IV CATH. 18 X 1 1/4 407500,2610528,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
IV CATH. 18 X 1 1/4,2610529,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
BENICAR (OLMESARTAN) TAB 20MG,2611009,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
KEPPRA (LEVETIRACETAM) INJ 500MG/5ML,2611012,CDM,636,RC,,,Both,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
IV CATH. 24 X 5/8,2613073,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
IV CATH. 20 X 1,2613077,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
MINI SPIKE 2N9106,2613080,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
MICARDIS (TELMISARTAN) TAB 40 MG,2615151,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
NACL,2619122,CDM,250,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
TWO-CAL H (ENTERAL FORMULA) GT 240ML,2620101,CDM,250,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
DESITIN DIAPER OINTMENT 1 OZ,2650015,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
LYRICA (PREGABALIN) CAP 75MG,2660009,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
GENTIAN VIOLET 1% : 2OZ,2660010,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
LYRICA (PREGABALIN) CAP 50MG,2660011,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SEROQUEL (QUETIAPINE) TAB 25MG,2660012,CDM,637,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
NOVOLIN N (INSULIN HUMAN-N) INJ : 1DOSE,2660017,CDM,636,RC,,,Both,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
MUTATION ID,3083914,CDM,301,RC,81355,HCPCS,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,88.2,100,,,fee schedule,Pays 100% Medicare OPPS,88.2,100,,,fee schedule,Pays 100% Medicare OPPS,88.2,100,,,fee schedule,Pays 100% Medicare OPPS,114.66,130,,,fee schedule,Pays 130% Medicare OPPS,86.67,120.37,,,fee schedule,120.37% of custom fee schedule,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,89.96,102,,,fee schedule,Pays 102% Medicare OPPS,18,90,,,percent of total billed charges,90% of total billed charges,90.13,125.18,,,fee schedule,125.18% of custom fee schedule,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,88.2,100,,,fee schedule,Pays 100% Medicare OPPS,79.38,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,86.67,120.37,,,fee schedule,120.37% of custom fee schedule,88.2,100,,,fee schedule,Pays 100% Medicare OPPS,114.66,130,,,fee schedule,Pays 130% Medicare OPPS,17,85,,,percent of total billed charges,85% of total billed charges,88.2,100,,,fee schedule,Pays 100% Medicare OPPS,11.3,114.66,
....MRI INJECTION GADOLINIUM CONTRAST,4400024,CDM,255,RC,A9579,HCPCS,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,4.07,18,
...........MRI MAGNEVIST INJ. SYR. 15ML,4476401,CDM,636,RC,A9579,HCPCS,Both,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
..........MRI MAGNEVIST INJ. SYR. 20ML,4476402,CDM,636,RC,A9579,HCPCS,Both,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
MRI MAGNEVIST VIAL 15ML,4476403,CDM,636,RC,A9579,HCPCS,Both,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
MRI MAGNEVIST VIAL 20ML,4476404,CDM,636,RC,A9579,HCPCS,Both,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
MRI MULTIHANCE VIAL 15ML,4476405,CDM,636,RC,A9579,HCPCS,Both,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
MRI MULTIHANCE VIAL 20ML,4476406,CDM,636,RC,A9579,HCPCS,Both,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
AEROSOL POCKET CHAMBER 100150,5550004,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
AEROSOL POCKET CHAMBER HUD100150,5550051,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
NEONATAL MASK 10 50505 MER MED,7900505,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
PEANUTS,7901050,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
WEBRIL 3 IN ROLL/STR,7901141,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
WEBRIL 6 IN ROLL/STR,7901143,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
.......NEBULIZER PREFILLED CK0005 500ML,7904429,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
AIRWAY PLASTIC,7905003,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
LEVINE TUBE 16 FR. 85753,7905055,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
LEVINE TUBE 18 FR. 85754,7905065,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
RING REMOVAL,7905073,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
CATH TRAY 14 FR. DYND10500,7905176,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
CATH FOLEY 6 FR. DYND11706,7905181,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
CATH FOLEY 10 FR. DYND11710,7905182,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
CATH FOLEY IRR. 3-WAY DYND11802,7905186,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
CATH FOLEY 16 FR. 30CC DYND11776,7905189,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
CERVICAL COLLAR SM,7905192,CDM,274,RC,L0120,HCPCS,Both,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
CERVICAL COLLAR MED,7905193,CDM,274,RC,L0120,HCPCS,Both,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
CERVICAL COLLAR LG,7905194,CDM,274,RC,L0120,HCPCS,Both,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
CATH FOLEY 24 FR. 30CC DYND11784,7905195,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
CATH FOLEY IRR 16FR 30CC 3-WAY DYND11800,7905197,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
CATH FOLEY IRR. 3-WAY DYND11803,7905199,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
CATH FOLEY IRR. 3-WAY DYND11804,7905200,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SPLINT WRIST PED/XS RIGHT (FIT/ADJUST),7905212,CDM,270,RC,L3908,HCPCS,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SUTURE 5-0 ETHILON 1668G,7905215,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
CATH FOLEY 14 FR. 30CC DYND11774,7905220,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
CATH TRAY 14 FR. 771114,7905224,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
STYLET INTUBATING 85865,7905240,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
HUGGIES LARGE,7905265,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
ARM SLING LARGE 8004-05,7905272,CDM,270,RC,A4565,HCPCS,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
NIPPLE SHIELD,7905292,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
RESTRAINT WRIST/ANKLE,7905313,CDM,274,RC,,,Both,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
URINE COLL (PED)STERILE,7905375,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
URINARY DRAINAGE BAG 6208,7905384,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
URINARY DRAINAGE BAG DYND15205,7905385,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
URINARY DRAINAGE BAG O.R. STER DYND15210,7905386,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
CURETTE STERILE CURVED 7 MM,7905410,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
CURETTE STERILE CURVED 8 MM,7905412,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
STERI STRIP 1/4 X 3 R1541,7905474,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
ANOSCOPE DISP,7905481,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
NU-GAUZE 1 IODOFORM 7833,7905506,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
NU-GAUZE 1/2 IODOFORM 7832,7905507,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
NU-GAUZE 1/4 IODOFORM 7831,7905508,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
GAUZE PACKING 1/4 IODOFORM NON256145,7905509,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
XEROFORM 1 X 8,7905510,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
GAUZE PACKING 1 IODOFORM NON256015,7905512,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
GAUZE PACKING 1/2 IODOFORM NON256125,7905513,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
GAUZE PACKING 1/4 PLAIN NON255145,7905514,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
GAUZE PACKING 2 IODOFORM NON256025,7905515,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
GAUZE PACKING 1/2 PLAIN NON255125,7905517,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
TRACHEAL TUBE 5.5 NASAL RAE 86288,7905541,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
**DO NOT USE**,7905596,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SUTURE 5-0 PROLENE 8661G,7905597,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SUTURE 5-0 ETHILON 698G,7905625,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
**DO NOT USE**,7905644,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
HAND TROL 130309A,7905686,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
HAND TROL 130326A 15FT CORD,7905687,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
STERI DRAPE 1016,7905702,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
TONSIL SPONGE,7905724,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
TRACHEAL TUBE 5.0 NASAL RAE 86287,7905728,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
TRACHEAL TUBE 4.5 NASAL RAE 86286,7905729,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
TRACHEAL TUBE 4.0 NASAL RAE 86285,7905730,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
DEFIB PAD 2345N,7905743,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
AIRWAY NASAL LF 24FR 5075-24,7905755,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
AIRWAY NASAL LF 34FR 5075-34,7905771,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
MOISTURE BARRIER,7905802,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
MOISTURE BARRIER REMEDY ESSENTIALS 2OZ,7905803,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
GROUNDING PAD/VALLEYLAB E7507,7905870,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
EYE SHIELD,7905936,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SUCTION CONNECTOR,7915001,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
..........OXYGEN .5,7915406,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SUCTION CANISTER 1200 CC 485410,7915701,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
O2 TUBING 1115 HUDSON,7919106,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
PENROSE DRAIN LATEX FREE 1/4 DYND50427,7950004,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
NU-GAUZE 1/2 PLAIN 7632,7950024,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
CENTRAL LINE DRESSING KIT DYND74661,7950035,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
CENTRAL LINE DRESSING KIT DYNJ03033,7950036,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
COLOSTOMY WAFER 401906,7950095,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
TRACHEOSTOMY TUBE HOLDER,7950127,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
COBAN 6,7950131,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
HYPERGEL,7950168,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
SAF-GEL 3 OZ.,7950175,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
NU-GAUZE 1 PLAIN 7633,7950217,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
NU-GAUZE 1/4 PLAIN 7631,7950219,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
WHIT,7950232,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
**DO NOT USE**,7950256,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
DRESSING MEPILEX BORDER 4 X 4,7950269,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
DRESSING KENDALL FOAM ISLAND 4 X 4,7950275,CDM,270,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
DRESSING OPTIFOAM NON ADHESIVE 6 X 6,7950294,CDM,272,RC,,,Outpatient,,,20,16,,17,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,percent of total billed charges,90% of total billed charges,7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13.74,68.7,,,percent of total billed charges,68.7% of total billed charges,16,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18,90,,,fee schedule,Pays 90% Medicare OPPS,11.6,58,,,percent of total billed charges,58% of total billed charges,4.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.07,18,
ELECTRODE BLADE INSULATED E1455,7950022,CDM,272,RC,,,Outpatient,,,21,16.8,,17.85,85,,,percent of total billed charges,85% of total billed charges,5.25,100,,,fee schedule,Pays 100% Medicare OPPS,5.25,100,,,fee schedule,Pays 100% Medicare OPPS,5.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.87,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.87,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.87,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.87,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,18.9,90,,,percent of total billed charges,90% of total billed charges,7.35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,14.43,68.7,,,percent of total billed charges,68.7% of total billed charges,16.8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,18.9,90,,,fee schedule,Pays 90% Medicare OPPS,12.18,58,,,percent of total billed charges,58% of total billed charges,4.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.28,18.9,
SUTURE 1 PDSII Z880G,1570518,CDM,272,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
SUTURE 2-0 VICRYL J532H,1570540,CDM,272,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
SUTURE 4-0 ETHILON 699G,1570568,CDM,272,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
SUTURE 4-0 PROLENE 8557H,1570574,CDM,272,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
SUTURE 4-0 MONOCRYL Y496G,1570598,CDM,272,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
SUTURE 2-0 PROLENE 8559H,1570616,CDM,272,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
ANOSCOPE DISP W/LIGHT 96MM X 23MM,1750075,CDM,270,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
ANOSCOPE DISP W/LIGHT 90MM X 18MM,1750076,CDM,270,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
TRIAMCINOLONE 0.1% OINTMENT,2600432,CDM,637,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
KCL 10% (POTASSIUM CL) UD LIQ 20MEQ,2600839,CDM,637,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
MERREM (MEROPENEM) 1GM VIAL,2601063,CDM,636,RC,,,Both,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
MERREM (MEROPENEM) 500MG VIAL,2601064,CDM,636,RC,,,Both,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
LOVENOX (ENOXAPARIN) INJ 30MG,2601411,CDM,636,RC,J1650,HCPCS,Both,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
VERSED (MIDAZOLAM HCL) INJ 50MG,2601427,CDM,636,RC,J2250,HCPCS,Both,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.22,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,0.23,125.18,,,fee schedule,125.18% of custom fee schedule,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,0.22,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.22,22.5,
ELIQUIS (APIXABAN) TAB 5MG,2602003,CDM,637,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
AGGRENOX CAP 25MG/200MG,2605147,CDM,637,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
NAROPIN (ROPIVACAINE) 0.5% VIAL 30ML,2610128,CDM,636,RC,,,Both,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
POWER PORT HUBER NEEDLE 20GA X 0.75INCH,2611015,CDM,270,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
NEEDLE SPINAL 20GA X 6,4000808,CDM,270,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
UNNA BOOT,7905083,CDM,272,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
ARM IMMOBILIZER FEMALE (FIT/ADJ) LG,7905147,CDM,274,RC,L3650,HCPCS,Both,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
ARM IMMOBILIZER MALE X-L (FIT/ADJ),7905148,CDM,274,RC,L3650,HCPCS,Both,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
ARM IMMOBILIZER FEMALE SM. (FIX & ADJ),7905149,CDM,274,RC,L3650,HCPCS,Both,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
ARM IMMOBILIZER FEMALE MED,7905150,CDM,270,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
ARM SLING UNIVERSAL 4535738,7905152,CDM,270,RC,A4565,HCPCS,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
ARM IMMOBILIZER FEMALE XLG,7905169,CDM,270,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
ARM IMMOBILIZER MALE SM,7905170,CDM,270,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
ARM IMMOBILIZER MALE MED,7905171,CDM,270,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
ARM IMMOBILIZER MALE LG(INCLUDES FIT/ADJ,7905172,CDM,274,RC,L3650,HCPCS,Both,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
SPLINT WRIST MED RT (FIT/ADJ),7905203,CDM,270,RC,L3908,HCPCS,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
SPLINT WRIST SM LT (FIT/ADJ),7905209,CDM,274,RC,L3908,HCPCS,Both,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
SPLINT WRIST XL LT (FIT/ADJ),7905210,CDM,270,RC,L3908,HCPCS,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
SPLINT WRIST XL RT (FIT/ADJ),7905211,CDM,274,RC,L3908,HCPCS,Both,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
SPLINT WRIST PED/XS LEFT (FIT/ADJUST),7905213,CDM,274,RC,L3908,HCPCS,Both,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
ARM SLING UNIVERSAL 5080221,7905214,CDM,270,RC,A4565,HCPCS,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
CATH TRAY 16 FR. 897216,7905229,CDM,270,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
CATH FOLEY IRR. 3-WAY DYND11805,7905252,CDM,270,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
ARM SLING UNIVERSAL ASL2105,7905257,CDM,270,RC,A4565,HCPCS,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
DRESSING DUO-DERM 187660,7905436,CDM,270,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
POST OP SHOE WOMENS SMALL,7905655,CDM,270,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
POST OP SHOE WOMENS MED,7905656,CDM,270,RC,A9270,HCPCS,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
POST OP SHOE WOMENS LARGE,7905657,CDM,274,RC,L3260,HCPCS,Both,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
POST OP SHOE MENS SMALL,7905660,CDM,270,RC,A9270,HCPCS,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
POST OP SHOE MENS MED,7905661,CDM,270,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
POST OP SHOE MENS XL,7905662,CDM,270,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
POST OP SHOE MENS LARGE,7905665,CDM,270,RC,A9270,HCPCS,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
PAD HEAT THERAPY 15 X 22,7905939,CDM,270,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
LACERATION TRAY LAC1001,7950019,CDM,270,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
LACERATION TRAY DYNJ03000,7950020,CDM,270,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
ELECTRODE FLAT BLADE 4 139112,7950021,CDM,272,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
LACERATION TRAY 05-5200,7950032,CDM,270,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
LACERATION TRAY DYNJ03108LF,7950034,CDM,270,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
DRESSING OPTIFOAM GENTLE EX SACRUM,7950309,CDM,272,RC,,,Outpatient,,,25,20,,21.25,85,,,percent of total billed charges,85% of total billed charges,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,percent of total billed charges,90% of total billed charges,8.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.18,68.7,,,percent of total billed charges,68.7% of total billed charges,20,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,22.5,90,,,fee schedule,Pays 90% Medicare OPPS,14.5,58,,,percent of total billed charges,58% of total billed charges,5.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.09,22.5,
DRESSING WOUND OPTICELL AG+ SILVER,7950316,CDM,272,RC,,,Outpatient,,,26,20.8,,22.1,85,,,percent of total billed charges,85% of total billed charges,6.5,100,,,fee schedule,Pays 100% Medicare OPPS,6.5,100,,,fee schedule,Pays 100% Medicare OPPS,6.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.3,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14.69,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.69,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.69,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.69,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,23.4,90,,,percent of total billed charges,90% of total billed charges,9.1,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17.86,68.7,,,percent of total billed charges,68.7% of total billed charges,20.8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,23.4,90,,,fee schedule,Pays 90% Medicare OPPS,15.08,58,,,percent of total billed charges,58% of total billed charges,5.3,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.1,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.3,23.4,
CATH FOLEY IRR. 3-WAY 18FR DYND11801,7905310,CDM,270,RC,,,Outpatient,,,29,23.2,,24.65,85,,,percent of total billed charges,85% of total billed charges,7.25,100,,,fee schedule,Pays 100% Medicare OPPS,7.25,100,,,fee schedule,Pays 100% Medicare OPPS,7.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,16.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,26.1,90,,,percent of total billed charges,90% of total billed charges,10.15,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,19.92,68.7,,,percent of total billed charges,68.7% of total billed charges,23.2,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,26.1,90,,,fee schedule,Pays 90% Medicare OPPS,16.82,58,,,percent of total billed charges,58% of total billed charges,5.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,24.65,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.91,26.1,
SUTURE FIBERLINK,1570645,CDM,272,RC,,,Outpatient,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,percent of total billed charges,90% of total billed charges,10.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,fee schedule,Pays 90% Medicare OPPS,17.4,58,,,percent of total billed charges,58% of total billed charges,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.11,27,
CLINDAMYCIN 300MG/2ML VIAL,2600011,CDM,636,RC,,,Both,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27,90,,,percent of total billed charges,90% of total billed charges,10.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,fee schedule,Pays 90% Medicare OPPS,17.4,58,,,percent of total billed charges,58% of total billed charges,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.11,27,
AMOXICILLIN SUSP 125MG/5ML 150ML,2600018,CDM,637,RC,,,Outpatient,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,percent of total billed charges,90% of total billed charges,10.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,fee schedule,Pays 90% Medicare OPPS,17.4,58,,,percent of total billed charges,58% of total billed charges,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.11,27,
ANCEF INJ : 500MG,2600030,CDM,636,RC,J0690,HCPCS,Both,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.87,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27,90,,,percent of total billed charges,90% of total billed charges,0.9,125.18,,,fee schedule,125.18% of custom fee schedule,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,fee schedule,Pays 90% Medicare OPPS,17.4,58,,,percent of total billed charges,58% of total billed charges,0.87,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.87,27,
SULAMYD 10% (SULFACETAMIDE SOD)OPHT DROP,2600330,CDM,637,RC,,,Outpatient,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,percent of total billed charges,90% of total billed charges,10.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,fee schedule,Pays 90% Medicare OPPS,17.4,58,,,percent of total billed charges,58% of total billed charges,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.11,27,
HYDROCORTISONE 1% LOTION 118ML,2600430,CDM,637,RC,,,Outpatient,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,percent of total billed charges,90% of total billed charges,10.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,fee schedule,Pays 90% Medicare OPPS,17.4,58,,,percent of total billed charges,58% of total billed charges,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.11,27,
CLINDAMYCIN 600MG/4ML VIAL,2601007,CDM,250,RC,,,Outpatient,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,percent of total billed charges,90% of total billed charges,10.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,fee schedule,Pays 90% Medicare OPPS,17.4,58,,,percent of total billed charges,58% of total billed charges,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.11,27,
PHENOBARB (PHENOBARBITAL NA) INJ 130MG,2601177,CDM,636,RC,J2560,HCPCS,Both,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,44.93,100,,,fee schedule,Pays 100% Medicare OPPS,44.93,100,,,fee schedule,Pays 100% Medicare OPPS,44.93,100,,,fee schedule,Pays 100% Medicare OPPS,47.12,130,,,fee schedule,Pays 130% Medicare OPPS,54.08,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,45.82,102,,,fee schedule,Pays 102% Medicare OPPS,27,90,,,percent of total billed charges,90% of total billed charges,56.24,125.18,,,fee schedule,125.18% of custom fee schedule,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,44.93,100,,,fee schedule,Pays 100% Medicare OPPS,40.43,90,,,fee schedule,Pays 90% Medicare OPPS,17.4,58,,,percent of total billed charges,58% of total billed charges,54.08,120.37,,,fee schedule,120.37% of custom fee schedule,36.25,100,,,fee schedule,Pays 100% Medicare OPPS,47.12,130,,,fee schedule,Pays 130% Medicare OPPS,25.5,85,,,percent of total billed charges,85% of total billed charges,44.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.4,56.24,
TALWIN (PENTAZOCINE LACTATE) INJ 30MG,2601185,CDM,636,RC,J3070,HCPCS,Both,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27,90,,,percent of total billed charges,90% of total billed charges,10.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,fee schedule,Pays 90% Medicare OPPS,17.4,58,,,percent of total billed charges,58% of total billed charges,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.11,27,
OPANA ER (OXYMORPHONE ER) TAB 5MG,2602015,CDM,637,RC,,,Outpatient,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,percent of total billed charges,90% of total billed charges,10.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,fee schedule,Pays 90% Medicare OPPS,17.4,58,,,percent of total billed charges,58% of total billed charges,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.11,27,
PREVACID (LANSOPRAZOLE) CAP 15MG,2602699,CDM,637,RC,,,Outpatient,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,percent of total billed charges,90% of total billed charges,10.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,fee schedule,Pays 90% Medicare OPPS,17.4,58,,,percent of total billed charges,58% of total billed charges,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.11,27,
ROXANOL (MORPHINE SULF) CONC LIQ 60MG,2603071,CDM,637,RC,,,Outpatient,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,percent of total billed charges,90% of total billed charges,10.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,fee schedule,Pays 90% Medicare OPPS,17.4,58,,,percent of total billed charges,58% of total billed charges,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.11,27,
FLEET PREP #1 (BISACODYL/SOD PHOS) KIT,2605003,CDM,637,RC,,,Outpatient,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,percent of total billed charges,90% of total billed charges,10.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,fee schedule,Pays 90% Medicare OPPS,17.4,58,,,percent of total billed charges,58% of total billed charges,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.11,27,
NUBAIN (NALBUPHINE) INJ 20MG,2605083,CDM,636,RC,J2300,HCPCS,Both,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.78,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27,90,,,percent of total billed charges,90% of total billed charges,3.93,125.18,,,fee schedule,125.18% of custom fee schedule,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,fee schedule,Pays 90% Medicare OPPS,17.4,58,,,percent of total billed charges,58% of total billed charges,3.78,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.78,27,
CYTOTEC VAG (MISOPROSTOL) VAG : 25MCG,2605124,CDM,637,RC,,,Outpatient,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,percent of total billed charges,90% of total billed charges,10.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,fee schedule,Pays 90% Medicare OPPS,17.4,58,,,percent of total billed charges,58% of total billed charges,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.11,27,
PREVACID (LANSOPRAZOLE) SOLUTAB 30MG,2605189,CDM,637,RC,,,Outpatient,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,percent of total billed charges,90% of total billed charges,10.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,fee schedule,Pays 90% Medicare OPPS,17.4,58,,,percent of total billed charges,58% of total billed charges,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.11,27,
ALBUTEROL (PROVENTIL) RT CHARGE,2619115,CDM,250,RC,,,Outpatient,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,percent of total billed charges,90% of total billed charges,10.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,fee schedule,Pays 90% Medicare OPPS,17.4,58,,,percent of total billed charges,58% of total billed charges,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.11,27,
RACEMIC EPI,2619121,CDM,250,RC,,,Outpatient,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,percent of total billed charges,90% of total billed charges,10.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,fee schedule,Pays 90% Medicare OPPS,17.4,58,,,percent of total billed charges,58% of total billed charges,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.11,27,
ATROVENT,2619306,CDM,250,RC,J7644,HCPCS,Outpatient,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,percent of total billed charges,90% of total billed charges,10.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,fee schedule,Pays 90% Medicare OPPS,17.4,58,,,percent of total billed charges,58% of total billed charges,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.11,27,
ALBUTEROL NEBULIZER SOL 2.5MG/3ML,2699994,CDM,250,RC,,,Outpatient,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,percent of total billed charges,90% of total billed charges,10.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,fee schedule,Pays 90% Medicare OPPS,17.4,58,,,percent of total billed charges,58% of total billed charges,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.11,27,
ABD BINDER 9 79-89070,7905153,CDM,270,RC,,,Outpatient,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,percent of total billed charges,90% of total billed charges,10.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,fee schedule,Pays 90% Medicare OPPS,17.4,58,,,percent of total billed charges,58% of total billed charges,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.11,27,
BREATHING CIRCUIT C1086,7905156,CDM,270,RC,,,Outpatient,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,percent of total billed charges,90% of total billed charges,10.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,fee schedule,Pays 90% Medicare OPPS,17.4,58,,,percent of total billed charges,58% of total billed charges,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.11,27,
GROUNDING PAD/VALLEYLAB INFANT E7510-25,7905479,CDM,270,RC,,,Outpatient,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,percent of total billed charges,90% of total billed charges,10.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,fee schedule,Pays 90% Medicare OPPS,17.4,58,,,percent of total billed charges,58% of total billed charges,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.11,27,
**DO NOT USE**,7905575,CDM,272,RC,,,Outpatient,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,percent of total billed charges,90% of total billed charges,10.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,fee schedule,Pays 90% Medicare OPPS,17.4,58,,,percent of total billed charges,58% of total billed charges,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.11,27,
VALVE SALEM SUMP ANTI REFLUX,7905592,CDM,270,RC,L0120,HCPCS,Outpatient,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,percent of total billed charges,90% of total billed charges,10.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,17.4,58,,,percent of total billed charges,58% of total billed charges,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.11,27,
INTRODUCER BOUGIE 15FR 9-0212-70,7905971,CDM,270,RC,,,Outpatient,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,percent of total billed charges,90% of total billed charges,10.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,fee schedule,Pays 90% Medicare OPPS,17.4,58,,,percent of total billed charges,58% of total billed charges,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.11,27,
CATH THORACIC 24FR 570531,7950012,CDM,272,RC,,,Outpatient,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,percent of total billed charges,90% of total billed charges,10.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,fee schedule,Pays 90% Medicare OPPS,17.4,58,,,percent of total billed charges,58% of total billed charges,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.11,27,
**DO NOT USE**,7950183,CDM,272,RC,,,Outpatient,,,30,24,,25.5,85,,,percent of total billed charges,85% of total billed charges,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,percent of total billed charges,90% of total billed charges,10.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,20.61,68.7,,,percent of total billed charges,68.7% of total billed charges,24,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,27,90,,,fee schedule,Pays 90% Medicare OPPS,17.4,58,,,percent of total billed charges,58% of total billed charges,6.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.11,27,
VENT CIRCUIT W/ PARALLEL PATIENT Y,7919118,CDM,272,RC,,,Outpatient,,,31,24.8,,26.35,85,,,percent of total billed charges,85% of total billed charges,7.75,100,,,fee schedule,Pays 100% Medicare OPPS,7.75,100,,,fee schedule,Pays 100% Medicare OPPS,7.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,6.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,17.52,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.52,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.52,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.52,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,27.9,90,,,percent of total billed charges,90% of total billed charges,10.85,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,21.3,68.7,,,percent of total billed charges,68.7% of total billed charges,24.8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,27.9,90,,,fee schedule,Pays 90% Medicare OPPS,17.98,58,,,percent of total billed charges,58% of total billed charges,6.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,26.35,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.31,27.9,
BLADE SAGITTAL SAW KM-3101,1570031,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
SUTURE 2-0 SILK C012D,1570533,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
SUTURE 4-0 PLAIN 1828H,1570572,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
SUTURE 4-0 VICRYL J522H,1570576,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
SUTURE 5-0 PROLENE 8556H,1570582,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
SUTURE 6-0 PROLENE 8697G,1570586,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
SUTURE 6-0 ETHILON 1665G,1570587,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
SUTURE 5-0 PROLENE 8635G,1570588,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
SUTURE 5-0 PROLENE 8618G,1570591,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
SUTURE 4-0 CHROMIC 1654G,1570594,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
SUTURE 4-0 SILK C014D,1570597,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
SUTURE 4-0 VICRYL J845G,1570605,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
SUTURE TAPE 1.3MM WH/BL & WH/BLK,1570644,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
SUTURE 2-0 SILK C016D,1570647,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
PLEDGET FELT RECTANGLE 3/8 X 3/16,1570788,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
PLEDGET FELT RECTANGLE 3/16 X 1/4,1570789,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
AMBULANCE GROUND MILEAGE,2000425,CDM,540,RC,A0425,HCPCS,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
SPLINT CONFORMABLE SYN 3 X FT,2005982,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
SPLINT CONFORMABLE SYN 4 X FT,2005983,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
SPLINT SYN 3 X FT,2005985,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
PAXIL CR (PAROXETINE) TAB 12.5MG,2600007,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
VALISONE (BETAMETHASONE VAL) 0.1% CRM,2600027,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
CYMBALTA (DULOXETINE) 30MG CAPSULE,2600080,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
NON-FORM $10 TAB,2600100,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
DEXTROSE 25% SYRINGE 10ML,2600129,CDM,250,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
RAZADYNE(GALANTAMINE) 8MG USE,2600136,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
FAMVIR (FAMCICLOVIR) TAB 250MG,2600143,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
NEO-SYNEPHRINE 0.5%(PHENYLEPHRINE)SPRAY,2600160,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
VITAMIN K (MEPHYTON) 5MG TAB,2600191,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
PHENERGAN (PROMETHAZINE) SUPP 12.5MG,2600218,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
TEARS NATURALE (ARTIFICIAL TEARS) OPHTH,2600301,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
AMOXICILLIN DROPS 50MG/ML 15ML,2600700,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
FEOSOL DR (FERROUS SULF) DRP 1ML,2600829,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
PHENERGAN (PROMETHAZINE HCL) SUPP 25MG,2600863,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
ZINACEF INJ 1.5GM,2601026,CDM,636,RC,J0697,HCPCS,Both,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2.62,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,2.73,125.18,,,fee schedule,125.18% of custom fee schedule,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,2.62,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.62,31.5,
AQUAMEPHYTON PED (PHYTONADIONE) INJ 1MG,2601261,CDM,636,RC,J3430,HCPCS,Both,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.98,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,4.14,125.18,,,fee schedule,125.18% of custom fee schedule,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,3.98,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.98,31.5,
DRAMAMINE (DIMENHYDRINATE) INJ : 50MG,2601308,CDM,636,RC,,,Both,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
AMBIEN (ZOLPIDEM TARTRATE) TAB 10MG,2602103,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
METHOTREXATE TAB 2.5MG,2602202,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
LIPITOR (ATORVASTATIN CA) TAB 10MG,2602273,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
RISPERDAL (RISPERIDONE) TAB 0.5MG,2602277,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
AUGMENTIN (AMOXICILLIN/CLAV) TAB 500MG,2602305,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
CEFTIN (CEFUROXIME AXETIL) TAB 250MG,2602310,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
BIAXIN (CLARITHROMYCIN) TAB 500MG,2602313,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
CORDARONE (AMIODARONE) TAB 200MG,2602600,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
ZETIA (EZETIMIBE) TAB 10 MG,2602708,CDM,250,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
CRESTOR (ROSUVASTATIN) TAB 10MG,2602709,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
NITROSTAT (NITRO) SL TAB BOTTLE 0.4MG,2602745,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
FLOMAX (TAMSULOSIN) CAP 0.4MG,2603055,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
SINGULAIR (MONTELUKAST) TAB 10MG,2605037,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
MAXIPIME (CEFEPIME) INJ 2GM,2605056,CDM,636,RC,,,Both,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
MAXIPIME (CEFEPIME) INJ 1GM,2605061,CDM,636,RC,,,Both,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
EVISTA (RALOXIFINE) TAB 60MG,2605113,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
EXELON (RIVASTIGMINE) CAP 3MG,2605114,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
EXELON (RIVASTIGMINE) CAP 1.5MG,2605115,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
SINGULAIR (MONTELUKAST) CHEW TAB 5MG,2605118,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
MS CONTIN (MORPHINE SULF CR) TAB 60MG,2605127,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
ETOMIDATE INJ : 20MG/10ML,2605139,CDM,250,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
DIDRONEL (ETIDRONATE DISODIUM) INJ: 50MG,2605162,CDM,250,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
EMLA (PRILOCAINE/LIDOCAINE)CRM : 5GM,2605183,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
LEXAPRO (ESCITALOPRAM) TAB 10MG,2605187,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
ACETAMINOPHEN 1000MG/100ML IV,2610127,CDM,250,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
POLOCAINE (MEPIVACAINE) 2% VIAL 50ML,2610129,CDM,636,RC,,,Both,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
PROPOFOL 1000MG/100ML VIAL,2610142,CDM,250,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
NACL 0.9% 10ML INJ,2610503,CDM,250,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
IV MEDLOCK (PLUG) MIS,2610534,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
KEPPRA (LEVETIRACETAM) TAB 500MG,2611010,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
ASPERCREME (TROLAMINE SALICYLATE) 85GM,2612001,CDM,637,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
XOPENEX,2619125,CDM,250,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
MUCOMYST (ACETYLCYSTEINE) 4ML NEB,2619209,CDM,250,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
MEFOXIN INJ (CEFOXITIN) 1GM,2662523,CDM,636,RC,,,Both,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
"MOLECULAR DIAG AMP PNA,MU",3000573,CDM,301,RC,83901,HCPCS,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
MOLECULAR DIAG ISOL OR EXT PNA,3000574,CDM,301,RC,83891,HCPCS,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
MOLECULAR DGN I&R,3000575,CDM,301,RC,83912,HCPCS,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
MOLECULAR DIAG SEP & ID,3000577,CDM,301,RC,83909,HCPCS,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
.ENZYMATIC DIGESTION,3083892,CDM,301,RC,83892,HCPCS,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
OPTICHAMBER DIAMOND 1079830,5550039,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
SUCTION CATH KIT 6 FR. SAFE T VAC 36626,7900006,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
SUCTION CATH KIT 8 FR. SAFE T VAC 36826,7900008,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
WEBRIL 4 IN ROLL/STR,7901142,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
SALEM SUMP TUBE 6 FR.,7905070,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
ABD BINDER 12 79-89090,7905165,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
CATH URETHERAL A/SZ,7905183,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
CLAVICLE BRACE LG (FIT/ADJ),7905217,CDM,274,RC,L3650,HCPCS,Both,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
SPONGES PEANUT,7905234,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
CATH TRAY 18 FR. 800362,7905258,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
DRESSING WET,7905408,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
DRESSING DUO-DERM 403332,7905437,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
STERI STRIP 1/4 X 4,7905471,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
ADAPTIC DRG 3 X 8,7905502,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
SUTURE 5-0 CHROMIC 687G,7905516,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
GELFOAM 3/4 X 2-3/8,7905532,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
ELECTRODE PLIACELL 01-3830,7905562,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
**DO NOT USE**,7905609,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
**DO NOT USE**,7905618,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
LAP SPONGE 4 X 18,7905693,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
BITE GUARD,7905796,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
HYDRAGRAN,7905800,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
DRESSING SORBSAN 9347,7905863,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
CATH KIT PUREWICK FEMALE EXTERNAL,7905872,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
VAGINAL SPECULUM/SHEATH (SM),7905921,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
CATH COUDE 14 FR. DYND11214H,7905942,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
PAD HEAT THERAPY 13 X 18,7905974,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
URINE METER,7905980,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
ET TUBE HOLDER,7915012,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
ET TUBE HOLDER PEDIATRIC,7915013,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
T ADAPTER,7915557,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
WATER TRAP,7915558,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
YANKAUERS SUCTION 40600,7915703,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
YANKAUER SUCTION 505016,7915706,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
.........SPUTUM CUP,7919445,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
ELECTRODE RED DOT 2271-3 ADULT,7950008,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
CATH THORACIC 32FR 570556,7950011,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
CATH THORACIC 32FR 8032,7950015,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
CATH THORACIC 36FR 8036,7950016,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
NEEDLE WHITACRE 405010,7950029,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
NEEDLE WHITACRE 405138,7950031,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
CATH THORACIC 24FR 8024,7950046,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
TUBING INSUFFLATION,7950086,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
TUBING INSUFFLATION 28-0212,7950087,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
SKIN STAPLER PMW35,7950159,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
NU-GAUZE 2 PLAIN 7634,7950162,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
SKIN STAPLER PMR35,7950177,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
ELASTIC BAND 2 STER. 3112,7950230,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
***DO NOT USE***,7950247,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
ALLDRESS 4 X 4,7950255,CDM,272,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
DRESSING MEPILEX BORDER 6 X 6,7950270,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
DRESSING KENDALL FOAM ISLAND 6 X 6,7950277,CDM,270,RC,,,Outpatient,,,35,28,,29.75,85,,,percent of total billed charges,85% of total billed charges,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,8.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,percent of total billed charges,90% of total billed charges,12.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24.05,68.7,,,percent of total billed charges,68.7% of total billed charges,28,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,31.5,90,,,fee schedule,Pays 90% Medicare OPPS,20.3,58,,,percent of total billed charges,58% of total billed charges,7.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.13,31.5,
SUTURE 3-0 VICRYL J864D,1570652,CDM,272,RC,,,Outpatient,,,39,31.2,,33.15,85,,,percent of total billed charges,85% of total billed charges,9.75,100,,,fee schedule,Pays 100% Medicare OPPS,9.75,100,,,fee schedule,Pays 100% Medicare OPPS,9.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,35.1,90,,,percent of total billed charges,90% of total billed charges,13.65,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,26.79,68.7,,,percent of total billed charges,68.7% of total billed charges,31.2,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,35.1,90,,,fee schedule,Pays 90% Medicare OPPS,22.62,58,,,percent of total billed charges,58% of total billed charges,7.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.15,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.94,35.1,
SUTURE 2-0 ETHILON 1674H,1570527,CDM,272,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
SUTURE 3-0 VICRYL J322H,1570560,CDM,272,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
SUTURE 4-0 CHROMIC 1637G,1570565,CDM,272,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
SUTURE 4-0 VICRYL J310H,1570579,CDM,272,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
SUTURE 3-0 DEXON 760841,1570581,CDM,272,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
SPLINT CONFORMABLE SYN 5 X FT,2005984,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
SPLINT SYN 4 X FT,2005986,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
SPLINT SYN 5 X FT,2005987,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
SPLINT SYN 6 X FT,2005988,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
CAST REMOVAL,2029705,CDM,450,RC,29705,HCPCS,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,274.32,130,,,fee schedule,Pays 130% Medicare OPPS,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,221.03,102,,,fee schedule,Pays 102% Medicare OPPS,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,195.03,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,211.02,100,,,fee schedule,Pays 100% Medicare OPPS,274.32,130,,,fee schedule,Pays 130% Medicare OPPS,34,85,,,percent of total billed charges,85% of total billed charges,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,8.15,274.32,
"New patient office or other outpatient visit, typically 30 min",2099203,CDM,450,RC,99203,HCPCS,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
CALCIUM GLUCONATE 10% VIAL 10ML,2600014,CDM,636,RC,,,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
MARCAINE (BUPIVACAINE) 0.25% VL 10ML,2600032,CDM,250,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
ATROPINE SULFATE INJ 0.4MG,2600050,CDM,636,RC,J0461,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.08,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,0.09,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,0.08,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.08,36,
CALCIUM CL 10% INJ 1000MG,2600052,CDM,636,RC,J3490,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
EPINEPHRINE SYRINGE 1MG,2600055,CDM,636,RC,J0171,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.88,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,0.91,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,0.88,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.88,36,
DOBUTREX (DOBUTAMINE) INJ 250MG,2600057,CDM,250,RC,J1250,HCPCS,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.87,120.37,,,fee schedule,120.37% of custom fee schedule,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,8.19,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,7.87,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.87,36,
LIDOCAINE 2% CARDIAC INJ 100MG,2600059,CDM,636,RC,J2001,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.02,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,0.03,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,0.02,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.02,36,
DERMOPLAST (BENZOCAINE/MENTHOL) SPRAY,2600074,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
PEPCID (FAMOTIDINE) INJ 20MG,2600087,CDM,250,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
NUPERCAINAL (DIBUCAINE) 1% 28 GM OINT,2600092,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
NON-FORM DOSE LIQ : 5ML,2600096,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
AURALGAN (BENZOCAINE/ANTIPYRINE) OTIC,2600101,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
AQUAPHOR 1.75OZ OINTMENT TUBE,2600111,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
MICONAZOLE (MICRO-GUARD) POWDER 85GM,2600115,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
"BUPIVACAINE 0.5% W/ EPI 1:200,000 DENTAL",2600135,CDM,250,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
ULORIC(FEBUXOSTAT)80MG TAB,2600140,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
ALBUTEROL NEBULIZER SOL 1.25MG/3ML,2600179,CDM,250,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
HYPERSAL(NACL)7% NEB,2600189,CDM,250,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
ANUSOL HC (HYDROCORTISONE) SUPP 25MG,2600200,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
LAMISIL (TERBINAFINE HCL) 1% CRM,2600436,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
XYLOCAINE 2% (LIDOCAINE HCL) JELLY 30ML,2600465,CDM,250,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
MASTISOL UD VIAL MIS,2600550,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
LEVSIN (HYOSCYAMINE) 0.125MG/1ML DROPS,2600840,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
AMPICILLIN INJ 125MG,2601003,CDM,636,RC,,,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
CARDIZEM (DILTIAZEM) INJ 25MG,2601016,CDM,250,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
ZINACEF INJ 750MG,2601024,CDM,636,RC,J0697,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.62,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,2.73,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,2.62,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.62,36,
DILAUDID (HYDROMORPHONE HCL) INJ 2MG,2601161,CDM,636,RC,J1170,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.18,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,4.34,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,4.18,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.18,36,
DILAUDID (HYDROMORPHONE HCL) INJ 1MG,2601163,CDM,636,RC,J1170,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4.18,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,4.34,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,4.18,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.18,36,
NUBAIN (NALBUPHINE) INJ 10MG,2601168,CDM,636,RC,J2300,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.78,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,3.93,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,3.78,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.78,36,
PENTOTHAL (THIOPENTAL SOD) INJ 500MG,2601176,CDM,636,RC,,,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
STADOL (BUTORPHANOL) INJ 1MG,2601178,CDM,636,RC,J0595,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.56,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,3.71,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,3.56,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.56,36,
PHENOBARB (PHENOBARBITAL NA) INJ 65MG,2601179,CDM,636,RC,J2560,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,44.93,100,,,fee schedule,Pays 100% Medicare OPPS,44.93,100,,,fee schedule,Pays 100% Medicare OPPS,44.93,100,,,fee schedule,Pays 100% Medicare OPPS,47.12,130,,,fee schedule,Pays 130% Medicare OPPS,54.08,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,45.82,102,,,fee schedule,Pays 102% Medicare OPPS,36,90,,,percent of total billed charges,90% of total billed charges,56.24,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,44.93,100,,,fee schedule,Pays 100% Medicare OPPS,40.43,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,54.08,120.37,,,fee schedule,120.37% of custom fee schedule,36.25,100,,,fee schedule,Pays 100% Medicare OPPS,47.12,130,,,fee schedule,Pays 130% Medicare OPPS,34,85,,,percent of total billed charges,85% of total billed charges,44.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.2,56.24,
EPINEPHRINE INJ AMPULE 1MG,2601251,CDM,636,RC,J0171,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.88,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,0.91,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,0.88,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.88,36,
FOLIC ACID INJ 1MG,2601253,CDM,636,RC,J3490,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
ATROPINE SULFATE INJ 1MG,2601266,CDM,636,RC,J0461,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.08,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,0.09,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,0.08,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.08,36,
VIT B-12 (CYANOCOBALAMIN) INJ 1MG,2601267,CDM,636,RC,J3420,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2.35,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,2.44,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,2.35,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2.35,36,
BUMEX (BUMETANIDE) INJ 1MG,2601275,CDM,250,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
HEPARIN FLUSH -LOC 100 U INJ 1000UNITS,2601311,CDM,636,RC,J1642,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.02,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,0.03,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,0.02,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.02,36,
EPHEDRINE INJ 50MG,2601312,CDM,250,RC,J0171,HCPCS,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.88,120.37,,,fee schedule,120.37% of custom fee schedule,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,0.91,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,0.88,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.88,36,
HALDOL (HALOPERIDOL LACTATE) INJ 5MG,2601317,CDM,636,RC,J1630,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,1.95,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,2.03,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,1.95,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1.95,36,
HEPARIN SODIUM INJ 5000 UNITS,2601319,CDM,636,RC,J1644,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.31,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,0.33,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,0.31,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.31,36,
SALINE MEDLOCK (SOD CHL 0.9%) INJ 10ML,2601321,CDM,272,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
DEMADEX (TORSEMIDE) INJ 20MG,2601338,CDM,636,RC,J3265,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
LASIX (FUROSEMIDE) INJ 20MG,2601343,CDM,636,RC,,,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
LASIX (FUROSEMIDE) INJ 100MG,2601344,CDM,636,RC,J1940,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.76,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,0.79,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,0.76,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.76,36,
XYLOCAINE 1% (LIDOCAINE HCL) INJ 5ML,2601348,CDM,636,RC,J2001,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.02,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,0.03,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,0.02,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.02,36,
XYLOCAINE 2% (LIDOCAINE HCL) VIAL 5ML,2601349,CDM,636,RC,J2001,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.02,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,0.03,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,0.02,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.02,36,
MARCAINE 0.25% (BUPIVACAINE) VIAL 30ML,2601355,CDM,636,RC,,,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
MAGNESIUM SULF 50% VIAL 5GM/10ML,2601357,CDM,636,RC,J3475,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.91,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,0.95,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,0.91,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.91,36,
MARCAINE 0.25% W/EPI(BUPIVACAINE)VL 10ML,2601358,CDM,250,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
MARCAINE (BUPIVACAINE) 0.5% VL 10ML,2601359,CDM,250,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
NEO-SYNEPHINE 1% (PHENYLEPHRINE)INJ 10MG,2601365,CDM,636,RC,J2370,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.85,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,4.01,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,3.85,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.85,36,
PITOCIN (OXYTOCIN) INJ 10 UNITS,2601373,CDM,636,RC,J2590,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
PROCAN IV (PROCAINAMIDE HCL) INJ 500MG,2601379,CDM,250,RC,J2690,HCPCS,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,123.32,120.37,,,fee schedule,120.37% of custom fee schedule,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,128.25,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,123.32,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10,128.25,
ROBINUL (GLYCOPYRROLATE) INJ 0.4MG,2601387,CDM,250,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
SOLU-CORTEF (HYDROCORTISONE) INJ 100MG,2601389,CDM,636,RC,J1720,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,21.51,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,22.37,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,21.51,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10,36,
SOLU-CORTEF (HYDROCORTISONE) INJ 250MG,2601390,CDM,636,RC,J1720,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,21.51,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,22.37,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,21.51,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10,36,
DEPO-MEDROL (METHYLPREDNISOLONE) 40MG,2601394,CDM,636,RC,J1030,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.97,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,9.33,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.97,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.97,36,
TIGAN (TRIMETHOBENZAMIDE) 200MG/2ML AMP,2601410,CDM,636,RC,J3250,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,51.61,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,53.68,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,51.61,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10,53.68,
VANCOCIN (VANCOMYCIN) INJ 500MG,2601414,CDM,636,RC,J3370,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.89,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,4.04,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,3.89,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.89,36,
LOVENOX (ENOXAPARIN) INJ 40MG,2601424,CDM,636,RC,J1650,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
VERSED (MIDAZOLAM HCL) INJ 5MG,2601429,CDM,636,RC,J2250,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.22,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,0.23,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,0.22,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.22,36,
VERSED (MIDAZOLAM HCL) INJ 2MG,2601430,CDM,636,RC,J2250,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.22,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,0.23,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,0.22,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.22,36,
OXYCONTIN (OXYCODONE CR) TAB 40MG,2602014,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
TRANEXAMIC ACID 1000MG INJ,2602143,CDM,636,RC,,,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
VALIUM (DIAZEPAM) INJ 10MG,2602146,CDM,636,RC,J3360,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.92,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,8.24,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,7.92,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.92,36,
SOLU-MEDROL (METHYLPREDNISOLONE)INJ 40MG,2602203,CDM,636,RC,J2920,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,5.15,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,5.36,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,5.15,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.15,36,
MARCAINE (BUPIVACAINE) SPINAL AMP 2ML,2602209,CDM,636,RC,,,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
GARAMYCIN (GENTAMICIN SULF) INJ 80MG,2602246,CDM,636,RC,J1580,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.2,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,3.33,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,3.2,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.2,36,
GARAMYCIN (GENTAMICIN SULF) INJ 20MG,2602260,CDM,636,RC,J1580,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.2,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,3.33,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,3.2,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.2,36,
SOD CHLORIDE CONC 23.4% INJ 4MEQ,2602268,CDM,636,RC,,,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
TOBRAMYCIN INJ 80MG,2602278,CDM,636,RC,J3260,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.13,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,3.25,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,3.13,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.13,36,
CEFZIL (CEFPROZIL) TAB 250MG,2602306,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
AUGMENTIN (AMOXICILLIN/CLAV) TAB 875MG,2602309,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
ZITHROMAX (AZITHROMYCIN) TAB 250MG,2602332,CDM,637,RC,Q0144,HCPCS,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
CIPRO (CIPROFLOXACIN) TAB 250MG,2602334,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
CIPRO (CIPROFLOXACIN) TAB 500MG,2602336,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
BENADRYL (DIPHENHYDRAMINE HCL) INJ 50MG,2602530,CDM,636,RC,J1200,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,1.41,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,1.46,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,1.41,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1.41,36,
DILANTIN (PHENYTOIN SOD) 250MG INJ,2602597,CDM,636,RC,J1165,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.54,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,0.56,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,0.54,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.54,36,
POTASSIUM CHLORIDE INJ 40MEQ/20ML,2602683,CDM,636,RC,J3480,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.19,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,0.2,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,0.19,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.19,36,
LANOXIN (DIGOXIN) INJ 0.5MG,2602686,CDM,636,RC,J1160,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,24.77,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,25.76,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,24.77,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10,36,
LASIX (FUROSEMIDE) INJ 40MG,2602689,CDM,636,RC,J1940,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.76,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,0.79,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,0.76,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.76,36,
PLAVIX (CLOPIDOGREL BISULFATE) TAB 75MG,2602773,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
NF-STERAPRED (DOSEPAK) TAB : 5MG,2602777,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
NORMODYNE (LABETALOL HCL) INJ 100MG,2602833,CDM,250,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
THORAZINE (CHLORPROMAZINE HCL) INJ 25MG,2602853,CDM,636,RC,J3230,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,40.94,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,42.57,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,40.94,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10,42.57,
LEVAQUIN TAB 500MG,2603003,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
MARCAINE 0.5% (BUPIVACAINE) VIAL 30ML,2603019,CDM,636,RC,,,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
MARCAINE 0.5% (BUPIVACAINE) VIAL 10ML,2603020,CDM,250,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
ATROPINE SULFATE INJ 1MG/10ML SYRINGE,2603021,CDM,636,RC,J0461,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.08,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,0.09,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,0.08,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.08,36,
SOD ACETATE INJ 2MEQ,2603077,CDM,636,RC,,,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
MULTITRACE-4 (TRACE ELEMENTS) INJ 1ML,2603078,CDM,250,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
LIPITOR (ATORVASTATIN CA) TAB 20MG,2603087,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
KAYEXALATE (SPS) LIQ 15GM,2605014,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
OIL OF CLOVE 3.7ML,2605021,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
MEGACE (MEGESTROL) 400MG/10ML,2605035,CDM,637,RC,S0179,HCPCS,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
CORDARONE INJ 150MG,2605048,CDM,636,RC,J0282,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
DIPROSONE (BETAMETHASONE) 0.05% CRM,2605065,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
DIPROSONE (BETAMETHASONE) 0.05% OINT,2605073,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
ZYPREXA (OLANZAPINE) TAB 5MG,2605075,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
XYLOCAINE 1% (LIDOCAINE HCL) AMP 10ML,2605086,CDM,636,RC,,,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
OMNICEF (CEFDINIR) CAP 300MG,2605090,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
HYSKON (DEXTRAN 70) IV,2605101,CDM,250,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
TRICOR (FENOFIBRATE) TAB 160MG,2605106,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
VASOPRESSIN INJ 20UNITS,2605158,CDM,636,RC,,,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
PROTONIX (PANTOPRAZOLE) TAB 40MG,2605175,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
SEROQUEL (QUETIAPINE) TAB 100MG,2605177,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
NUPERCAINAL (DIBUCAINE) 1% : 30GM,2610007,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
K-PHOS (POTASSIUM PHOS) INJ 4.4MEQ VIAL,2610112,CDM,250,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
ANCEF 2GM 50ML IVPB PREMIX,2610132,CDM,250,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
STERILE WATER INJ 10ML,2610502,CDM,250,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
IRRIGATION SET BRAUN V4639,2610506,CDM,272,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
IV BLOOD SET MIS,2610512,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
ALBUTEROL NEBULIZER SOL 2.5MG/3ML,2610541,CDM,250,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
BLOOD SET Y-TYP,2610542,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
NON-FORM NUTRITIONAL LIQ : 1ML,2620000,CDM,637,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
DUONEB NEBULIZER SOL 2.5-0.5MG/3ML,2660028,CDM,250,RC,J7620,HCPCS,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
INSTA-GLUCOSE GEL/JELLY 40%,2662045,CDM,250,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
DECADRON (DEXAMETHASONE) NEB 2MG,2699985,CDM,250,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
RACEMIC EPI NEB TX NEB,2699986,CDM,250,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
ATROVENT (IPRATROPIUM TX) NEB 0.5MG,2699993,CDM,250,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,10,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
"DRUG SCREEN,SERUM(9 PANEL)",3000568,CDM,301,RC,80377,HCPCS,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
Collection of venous blood by venipuncture,3036415,CDM,302,RC,36415,HCPCS,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,3,100,,,fee schedule,Pays 100% Medicare OPPS,3,100,,,fee schedule,Pays 100% Medicare OPPS,3,100,,,fee schedule,Pays 100% Medicare OPPS,11.14,130,,,fee schedule,Pays 130% Medicare OPPS,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3.06,102,,,fee schedule,Pays 102% Medicare OPPS,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,3,100,,,fee schedule,Pays 100% Medicare OPPS,2.7,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8.57,100,,,fee schedule,Pays 100% Medicare OPPS,11.14,130,,,fee schedule,Pays 130% Medicare OPPS,34,85,,,percent of total billed charges,85% of total billed charges,3,100,,,fee schedule,Pays 100% Medicare OPPS,2.7,36,
RC AB ID/EACH SELECTED REAGENT CELL,3086885,CDM,300,RC,86885,HCPCS,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,179.8,130,,,fee schedule,Pays 130% Medicare OPPS,8.65,120.37,,,fee schedule,120.37% of custom fee schedule,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,136.65,102,,,fee schedule,Pays 102% Medicare OPPS,36,90,,,percent of total billed charges,90% of total billed charges,9,125.18,,,fee schedule,125.18% of custom fee schedule,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,120.57,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.65,120.37,,,fee schedule,120.37% of custom fee schedule,138.31,100,,,fee schedule,Pays 100% Medicare OPPS,179.8,130,,,fee schedule,Pays 130% Medicare OPPS,34,85,,,percent of total billed charges,85% of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,8.65,179.8,
RC PRETREATMENT W/ENZYMES PER CELL (RC),3086971,CDM,300,RC,86971,HCPCS,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,370.6,130,,,fee schedule,Pays 130% Medicare OPPS,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,266.86,102,,,fee schedule,Pays 102% Medicare OPPS,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,235.46,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,285.08,100,,,fee schedule,Pays 100% Medicare OPPS,370.6,130,,,fee schedule,Pays 130% Medicare OPPS,34,85,,,percent of total billed charges,85% of total billed charges,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,8.15,370.6,
CT GASTROGRAFIN 30ML,4000034,CDM,255,RC,Q9963,HCPCS,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,8.15,36,
PEAK FLOWMETER 1801 HUDSON,5550018,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
PEAK FLOWMETER 002068 CAREFUSION,5550040,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
PEAK FLOWMETER HS756 LOW RANGE,5550042,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
SPUTUM COLLECTION,5594664,CDM,410,RC,94640,HCPCS,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,172.23,102,,,fee schedule,Pays 102% Medicare OPPS,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,151.96,90,,,fee schedule,Pays 90% Medicare OPPS,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,168.43,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,34,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,8.15,218.97,
LEVINE TUBES 10FR,7905058,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
SPLINT WRIST SM RT (INCLUDES FIT/ADJ),7905202,CDM,274,RC,L3908,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
SPLINT WRIST LG RT (FIT/ADJ),7905205,CDM,274,RC,L3908,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
SPLINT WRIST LG LT (FIT & ADJ),7905206,CDM,274,RC,L3908,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
SPLINT WRIST MED LT (FIT/ADJ),7905208,CDM,274,RC,L3908,HCPCS,Both,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
FLATUS BAG,7905235,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
HEAD HALTER,7905248,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
SUSPENSORY SM,7905341,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
SUSPENSORY MED,7905342,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
SUSPENSORY LG,7905344,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
SUSPENSORY X-LG,7905345,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
SUSPENSORY MED W/LEG STRAPS 201161,7905346,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
SUSPENSORY LG W/O LEG STRAPS 202430,7905347,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
CATH DELEE SUCT.,7905355,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
CATH DELEE SUCTION,7905357,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
VAGINAL IRRIG SET,7905390,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
DRESSING MEPITEL 3 X 4,7905438,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
GAUZE FLUFF 36 X 18,7905528,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
TRACHEAL TUBE 6.0 NASAL RAE 86212,7905542,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
TRACHEAL TUBE 6.5 NASAL RAE 86213,7905543,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
**DO NOT USE**,7905620,CDM,272,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
**DO NOT USE**,7905623,CDM,272,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
TRACHEAL TUBE 7.5 NASAL RAE 86215,7905658,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
TRACHEAL TUBE 7.0 NASAL RAE 86214,7905659,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
FEED TUBE INFANT 8 FR,7905676,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
NEEDLE MAT,7905694,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
TRACHEAL TUBE 6.5 ORAL RAE 86203,7905733,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
TRACHEAL TUBE 6.0 ORAL RAE 86202,7905734,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
TRACHEAL TUBE 5.5 ORAL RAE 86201,7905735,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
LAP SPONGE 18 X 18,7905752,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
OP SITE 6 X 6,7905766,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
CHLORAPREP 26 ML APPLICATOR,7905807,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
CHLORAPREP 26 ML APPLICATOR 930815,7905810,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
STOMA MEASURING DEVICE 315555,7905849,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
BREATHING CIRCUIT PEDIATRIC,7905852,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
CATH PED. FOLEY 8 FR.,7905871,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
CYSTO PACK IV,7905905,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
NEEDLE ELECTRODE,7905914,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
PAD HEAT THERAPY 18 X 26,7905940,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
CATH COUDE 16 FR. DYND11216H,7905943,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
BIPAP CIRCUIT,7915011,CDM,272,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
BIPAP CIRCUIT 73-1069210,7915014,CDM,272,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
BIPAP CIRCUIT 73-582073,7915015,CDM,272,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
SUCTION CATHETER,7915702,CDM,272,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
SUCTION TUBING 72,7915704,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
...MUCUS TRAP,7915705,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
TUBING CORRUGATED 1418,7919206,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
CATH THORACIC 36FR 570564,7950042,CDM,272,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
EYE PROTECTOR POSEY,7950088,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
BITE BLOCK COMFORT,7950208,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
ELASTIC BAND 4 STER. 3114,7950210,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
**DO NOT USE**,7950251,CDM,272,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
ELASTIC BAND 3 STER. 3113,7950268,CDM,270,RC,,,Outpatient,,,40,32,,34,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,36,90,,,percent of total billed charges,90% of total billed charges,14,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,27.48,68.7,,,percent of total billed charges,68.7% of total billed charges,32,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,23.2,58,,,percent of total billed charges,58% of total billed charges,8.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,34,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.15,36,
JANUVIA (SITAGLIPTIN) 100MG TAB,262517,CDM,637,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
SLEEVE KII Z THREAD CTS02,1570086,CDM,272,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
SUTURE 0 ETHIBOND CX45D,1570504,CDM,272,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
SUTURE 3-0 SILK C013D,1570554,CDM,272,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
SUTURE 2-0 VICRYL J775D,1570620,CDM,272,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
SUTURE 3-0 VICRYL J772D,1570621,CDM,272,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
SLEEVE KII Z THREAD CTS01,1570792,CDM,272,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
LOCKING DEVICE AND BIOPSY CAP SYSTEM,1750025,CDM,272,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
INDIGO CARMINE 0.8% SOLUTION,2600008,CDM,636,RC,,,Both,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
BACTROBAN (MUPIROCIN) 0.02% OINT,2600064,CDM,637,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
DIPRIVAN (PROPOFOL 1%) VIAL 20ML,2601151,CDM,250,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
DETROL L.A. (TOLTERODINE) CAP 2MG,2605005,CDM,637,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
CLEOCIN 900MG/50ML IVPB PREMIX,2605062,CDM,250,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
FLEET PREP KIT#3,2660002,CDM,637,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
DAKIN'S SOLUTION HALF STRENGTH 0.25%,2661916,CDM,250,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
XARELTO (RIVAROXABAN) TAB 10MG,2662785,CDM,637,RC,A9270,HCPCS,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
"MOLECULAR DIAG, INTERPRET",3000210,CDM,301,RC,83912,HCPCS,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
"MOLECULAR DIAG, ISOLATION",3000211,CDM,301,RC,83890,HCPCS,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
"MOLECULAR DIAG, NAP",3000212,CDM,301,RC,83896,HCPCS,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
"MOLECULAR DIAG,ISO/E HPNA",3083891,CDM,301,RC,83891,HCPCS,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
"MOLECULAR DIAG, DOT",3083893,CDM,301,RC,83893,HCPCS,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
"MOLECULAR DIAG, MUT ID",3083904,CDM,301,RC,83904,HCPCS,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
EVACUATED CONTAINER /PARACENTIS,4600100,CDM,272,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
"AMBU BAG PEDIATRIC NEO,INF,TODDLER MASK",7900005,CDM,270,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
KNEE BRACE SM (INCLUDES FIT/ADJ),7905261,CDM,274,RC,L1830,HCPCS,Both,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,90,100,,,fee schedule,Pays 100% Medicare OPPS,90,100,,,fee schedule,Pays 100% Medicare OPPS,90,100,,,fee schedule,Pays 100% Medicare OPPS,123.05,130,,,fee schedule,Pays 130% Medicare OPPS,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,91.8,102,,,fee schedule,Pays 102% Medicare OPPS,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,90,100,,,fee schedule,Pays 100% Medicare OPPS,81,90,,,fee schedule,Pays 90% Medicare OPPS,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.65,100,,,fee schedule,Pays 100% Medicare OPPS,123.05,130,,,fee schedule,Pays 130% Medicare OPPS,38.25,85,,,percent of total billed charges,85% of total billed charges,90,100,,,fee schedule,Pays 100% Medicare OPPS,9.17,123.05,
KNEE BRACE MED (INCLUDES FIT/ADJ),7905263,CDM,274,RC,L1830,HCPCS,Both,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,90,100,,,fee schedule,Pays 100% Medicare OPPS,90,100,,,fee schedule,Pays 100% Medicare OPPS,90,100,,,fee schedule,Pays 100% Medicare OPPS,123.05,130,,,fee schedule,Pays 130% Medicare OPPS,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,91.8,102,,,fee schedule,Pays 102% Medicare OPPS,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,90,100,,,fee schedule,Pays 100% Medicare OPPS,81,90,,,fee schedule,Pays 90% Medicare OPPS,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.65,100,,,fee schedule,Pays 100% Medicare OPPS,123.05,130,,,fee schedule,Pays 130% Medicare OPPS,38.25,85,,,percent of total billed charges,85% of total billed charges,90,100,,,fee schedule,Pays 100% Medicare OPPS,9.17,123.05,
KNEE BRACE XL (FIT/ADJ),7905264,CDM,274,RC,L1830,HCPCS,Both,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,90,100,,,fee schedule,Pays 100% Medicare OPPS,90,100,,,fee schedule,Pays 100% Medicare OPPS,90,100,,,fee schedule,Pays 100% Medicare OPPS,123.05,130,,,fee schedule,Pays 130% Medicare OPPS,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,91.8,102,,,fee schedule,Pays 102% Medicare OPPS,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,90,100,,,fee schedule,Pays 100% Medicare OPPS,81,90,,,fee schedule,Pays 90% Medicare OPPS,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.65,100,,,fee schedule,Pays 100% Medicare OPPS,123.05,130,,,fee schedule,Pays 130% Medicare OPPS,38.25,85,,,percent of total billed charges,85% of total billed charges,90,100,,,fee schedule,Pays 100% Medicare OPPS,9.17,123.05,
KNEE BRACE LG (INCLUDES FIT/ADJ),7905266,CDM,274,RC,L1830,HCPCS,Both,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,90,100,,,fee schedule,Pays 100% Medicare OPPS,90,100,,,fee schedule,Pays 100% Medicare OPPS,90,100,,,fee schedule,Pays 100% Medicare OPPS,123.05,130,,,fee schedule,Pays 130% Medicare OPPS,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,91.8,102,,,fee schedule,Pays 102% Medicare OPPS,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,90,100,,,fee schedule,Pays 100% Medicare OPPS,81,90,,,fee schedule,Pays 90% Medicare OPPS,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.65,100,,,fee schedule,Pays 100% Medicare OPPS,123.05,130,,,fee schedule,Pays 130% Medicare OPPS,38.25,85,,,percent of total billed charges,85% of total billed charges,90,100,,,fee schedule,Pays 100% Medicare OPPS,9.17,123.05,
***DO NOT USE***,7905276,CDM,272,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
***DO NOT USE***,7905277,CDM,272,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
BAIR HUGGER BLANKET 52500,7905319,CDM,270,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
BAIR HUGGER BLANKET 62200,7905320,CDM,270,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
BAIR HUGGER BLANKET,7905321,CDM,270,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
LUMBAR PUN TRAY PED 4304C,7905417,CDM,270,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
**DO NOT USE**,7905585,CDM,272,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
**DO NOT USE**,7905587,CDM,272,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
**DO NOT USE**,7905619,CDM,272,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
**DO NOT USE**,7905829,CDM,272,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
NETI POT SINUCLEANSE STARTER KIT,7950023,CDM,270,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
BREATHING CIRCUIT ADULT 60,7950250,CDM,270,RC,,,Outpatient,,,45,36,,38.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,40.5,90,,,percent of total billed charges,90% of total billed charges,15.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,30.92,68.7,,,percent of total billed charges,68.7% of total billed charges,36,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,26.1,58,,,percent of total billed charges,58% of total billed charges,9.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.17,40.5,
SUSPENSORY XL W/LEG STRAPS 201352,7905348,CDM,270,RC,,,Outpatient,,,47,37.6,,39.95,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.57,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,26.56,56.5,,,percent of total billed charges,56.5 percent of total billed charges,26.56,56.5,,,percent of total billed charges,56.5 percent of total billed charges,26.56,56.5,,,percent of total billed charges,56.5 percent of total billed charges,26.56,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,42.3,90,,,percent of total billed charges,90% of total billed charges,16.45,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,32.29,68.7,,,percent of total billed charges,68.7% of total billed charges,37.6,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,27.26,58,,,percent of total billed charges,58% of total billed charges,9.57,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,39.95,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.57,42.3,
SUSPENSORY LG W/LEG STRAPS 201255,7905349,CDM,270,RC,,,Outpatient,,,47,37.6,,39.95,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.57,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,26.56,56.5,,,percent of total billed charges,56.5 percent of total billed charges,26.56,56.5,,,percent of total billed charges,56.5 percent of total billed charges,26.56,56.5,,,percent of total billed charges,56.5 percent of total billed charges,26.56,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,42.3,90,,,percent of total billed charges,90% of total billed charges,16.45,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,32.29,68.7,,,percent of total billed charges,68.7% of total billed charges,37.6,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,27.26,58,,,percent of total billed charges,58% of total billed charges,9.57,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,39.95,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.57,42.3,
CANISTER VITRUVIAN LIPOSUCTION LF,7950344,CDM,270,RC,,,Outpatient,,,49,39.2,,41.65,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,27.69,56.5,,,percent of total billed charges,56.5 percent of total billed charges,27.69,56.5,,,percent of total billed charges,56.5 percent of total billed charges,27.69,56.5,,,percent of total billed charges,56.5 percent of total billed charges,27.69,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,44.1,90,,,percent of total billed charges,90% of total billed charges,17.15,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,33.66,68.7,,,percent of total billed charges,68.7% of total billed charges,39.2,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,28.42,58,,,percent of total billed charges,58% of total billed charges,9.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,41.65,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.98,44.1,
OBSERVATION ADDITIONAL HR,400002,CDM,762,RC,99219,HCPCS,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
K-WIRE 0.9MM,1570356,CDM,278,RC,C1713,HCPCS,Both,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
SUTURE 0 CHROMIC 812H,1570500,CDM,272,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
SUTURE 0 CHROMIC L114G,1570502,CDM,272,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
SUTURE 2-0 CHROMIC 811H,1570524,CDM,272,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
SUTURE 2-0 VICRYL J259H,1570536,CDM,272,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
SUTURE 2-0 VICRYL J266J,1570537,CDM,272,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
SUTURE 2-0 VICRYL J306H,1570538,CDM,272,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
FORCEPS BABCOCK GRASPING DISPO,1570801,CDM,272,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
STYLET GLIDERITE SU,1570850,CDM,272,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
LARYNGOSCOPE HANDLE/BLADE MAC 3,1570858,CDM,272,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
LARYNGOSCOPE HANDLE/BLADE MAC 4,1570859,CDM,272,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
LARYNGOSCOPE HANDLE/BLADE MILLER 2,1570862,CDM,272,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
OBSERVATION EA ADD H,2000012,CDM,762,RC,99219,HCPCS,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
FILTERLINE SET,2092962,CDM,270,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
FILTERLINE SET 0683-00-0470-25,2092963,CDM,270,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
NEOSPORIN (NEOMYCIN/BACI/POLY B)EYE OINT,2600034,CDM,637,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
DEXTROSE 50% INJ : 50ML,2600053,CDM,250,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
OPTICHAMBER (SPACER FOR MDI),2600148,CDM,270,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
MAGNESIUM SULFATE 2GM IV PREMIX,2600183,CDM,250,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
MONISTAT-7 (MICONAZOLE NIT) VAG CRM,2600260,CDM,637,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
PILOCAR 1% (PILOCARPINE) OPHT DROP,2600316,CDM,637,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
AMOXICILLIN SUSP 250MG/5ML 100ML,2600702,CDM,637,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
KEFLEX (CEPHALEXIN) LIQ 125MG/5ML,2600718,CDM,637,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
PROMETHAZINE GEL 25MG/0.4ML,2600864,CDM,637,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
LEVOPHED (NOREPINEPHRINE) INJ 4MG/4ML,2601009,CDM,250,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
UNASYN (AMPICILLIN/SULBACTAM) INJ 1.5GM,2601052,CDM,636,RC,J0295,HCPCS,Both,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.17,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,3.29,125.18,,,fee schedule,125.18% of custom fee schedule,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,3.17,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.17,45,
METHYLENE BLUE 0.5% INJ 10ML,2601361,CDM,636,RC,Q9968,HCPCS,Both,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,8.08,100,,,fee schedule,Pays 100% Medicare OPPS,8.08,100,,,fee schedule,Pays 100% Medicare OPPS,8.08,100,,,fee schedule,Pays 100% Medicare OPPS,9.73,130,,,fee schedule,Pays 130% Medicare OPPS,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.24,102,,,fee schedule,Pays 102% Medicare OPPS,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,8.08,100,,,fee schedule,Pays 100% Medicare OPPS,7.27,90,,,fee schedule,Pays 90% Medicare OPPS,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,7.49,100,,,fee schedule,Pays 100% Medicare OPPS,9.73,130,,,fee schedule,Pays 130% Medicare OPPS,42.5,85,,,percent of total billed charges,85% of total billed charges,8.08,100,,,fee schedule,Pays 100% Medicare OPPS,7.27,45,
VANCOMYCIN ORAL SOLN : 250MG/5ML BOTTLE,2601417,CDM,637,RC,J3370,HCPCS,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.89,120.37,,,fee schedule,120.37% of custom fee schedule,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,4.04,125.18,,,fee schedule,125.18% of custom fee schedule,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,3.89,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.89,45,
VASOTEC (ENALAPRILAT) INJ 2.5MG,2601421,CDM,636,RC,,,Both,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
DECADRON (DEXAMETHASONE) INJ 4MG,2602208,CDM,636,RC,J1100,HCPCS,Both,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,0.16,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,0.16,125.18,,,fee schedule,125.18% of custom fee schedule,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,0.16,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.16,45,
NORCURON (VECURONIUM) INJ 10MG,2603004,CDM,250,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
LOVENOX (ENOXAPARIN) INJ 60MG,2603052,CDM,636,RC,J1650,HCPCS,Both,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
CALMOSEPTINE (ZINC OXIDE/MENTHOL) OINT,2605055,CDM,637,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
IMITREX (SUMATRIPTAN) INJ 6MG,2605116,CDM,636,RC,J3030,HCPCS,Both,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,30.09,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,31.3,125.18,,,fee schedule,125.18% of custom fee schedule,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,30.09,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29,45,
MORPHINE SULF INJ 5MG,2605125,CDM,636,RC,J2270,HCPCS,Both,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.57,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,3.72,125.18,,,fee schedule,125.18% of custom fee schedule,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,3.57,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.57,45,
PULMICORT 0.25MG(BUDESONIDE),2605142,CDM,250,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
NEOSYNEPH 10% (PHENYLEPHRINE) OPHT DROP,2605181,CDM,250,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
COMPAZINE (PROCHLORPERAZINE) INJ 10MG,2606050,CDM,636,RC,J0780,HCPCS,Both,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,5.04,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,5.25,125.18,,,fee schedule,125.18% of custom fee schedule,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,5.04,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.04,45,
NF-DEX/ETHAN (DEX 5% ALCOHOL 5%) 500ML,2610036,CDM,250,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
DEXTROSE 5% INJ 25ML,2610067,CDM,250,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
DECADRON,2615555,CDM,250,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
LIDODERM (LIDOCAINE) 5% PATCH,2660014,CDM,637,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
PULMICORT 0.5MG(BUDESONIDE),2699987,CDM,250,RC,J7626,HCPCS,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
XOPENEX 1.25MG(LEVALBUTEROL),2699988,CDM,250,RC,J7614,HCPCS,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
XOPENEX 0.63MG(LEVALBUTEROL),2699989,CDM,250,RC,J7614,HCPCS,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
XOPENEX 0.31MG(LEVALBUTEROL),2699990,CDM,250,RC,J7614,HCPCS,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
HAEMOPHILUS ID,3000140,CDM,306,RC,87158,HCPCS,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,7.74,100,,,fee schedule,Pays 100% Medicare OPPS,7.74,100,,,fee schedule,Pays 100% Medicare OPPS,7.74,100,,,fee schedule,Pays 100% Medicare OPPS,10.06,130,,,fee schedule,Pays 130% Medicare OPPS,7.92,120.37,,,fee schedule,120.37% of custom fee schedule,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,7.89,102,,,fee schedule,Pays 102% Medicare OPPS,45,90,,,percent of total billed charges,90% of total billed charges,8.24,125.18,,,fee schedule,125.18% of custom fee schedule,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,7.74,100,,,fee schedule,Pays 100% Medicare OPPS,6.96,90,,,fee schedule,Pays 90% Medicare OPPS,29,58,,,percent of total billed charges,58% of total billed charges,7.92,120.37,,,fee schedule,120.37% of custom fee schedule,7.74,100,,,fee schedule,Pays 100% Medicare OPPS,10.06,130,,,fee schedule,Pays 130% Medicare OPPS,42.5,85,,,percent of total billed charges,85% of total billed charges,7.74,100,,,fee schedule,Pays 100% Medicare OPPS,6.96,45,
.T PROTEIN (SPEP W IMMUNO),3000296,CDM,301,RC,84155,HCPCS,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,3.67,100,,,fee schedule,Pays 100% Medicare OPPS,3.67,100,,,fee schedule,Pays 100% Medicare OPPS,3.67,100,,,fee schedule,Pays 100% Medicare OPPS,4.77,130,,,fee schedule,Pays 130% Medicare OPPS,5.55,120.37,,,fee schedule,120.37% of custom fee schedule,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3.74,102,,,fee schedule,Pays 102% Medicare OPPS,45,90,,,percent of total billed charges,90% of total billed charges,5.77,125.18,,,fee schedule,125.18% of custom fee schedule,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,3.67,100,,,fee schedule,Pays 100% Medicare OPPS,3.3,90,,,fee schedule,Pays 90% Medicare OPPS,29,58,,,percent of total billed charges,58% of total billed charges,5.55,120.37,,,fee schedule,120.37% of custom fee schedule,3.67,100,,,fee schedule,Pays 100% Medicare OPPS,4.77,130,,,fee schedule,Pays 130% Medicare OPPS,42.5,85,,,percent of total billed charges,85% of total billed charges,3.67,100,,,fee schedule,Pays 100% Medicare OPPS,3.3,45,
Manual urinalysis test with examination without using microscope,3000323,CDM,307,RC,81002,HCPCS,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,4.52,130,,,fee schedule,Pays 130% Medicare OPPS,3.86,120.37,,,fee schedule,120.37% of custom fee schedule,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3.54,102,,,fee schedule,Pays 102% Medicare OPPS,45,90,,,percent of total billed charges,90% of total billed charges,4.02,125.18,,,fee schedule,125.18% of custom fee schedule,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,3.13,90,,,fee schedule,Pays 90% Medicare OPPS,29,58,,,percent of total billed charges,58% of total billed charges,3.86,120.37,,,fee schedule,120.37% of custom fee schedule,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,4.52,130,,,fee schedule,Pays 130% Medicare OPPS,42.5,85,,,percent of total billed charges,85% of total billed charges,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,3.13,45,
MOLECULAR DIAG AMP OF PNA,3000576,CDM,301,RC,83900,HCPCS,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
"DRUG SCREEN STUDENT,UA",3000612,CDM,301,RC,80377,HCPCS,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
"DRUG SCREEN, 5 PANEL QUEST",3000667,CDM,301,RC,80376,HCPCS,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
THYROXINE BINDING GLOBULIN,3000731,CDM,306,RC,84442,HCPCS,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,14.78,100,,,fee schedule,Pays 100% Medicare OPPS,14.78,100,,,fee schedule,Pays 100% Medicare OPPS,14.78,100,,,fee schedule,Pays 100% Medicare OPPS,19.21,130,,,fee schedule,Pays 130% Medicare OPPS,17.61,120.37,,,fee schedule,120.37% of custom fee schedule,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.07,102,,,fee schedule,Pays 102% Medicare OPPS,45,90,,,percent of total billed charges,90% of total billed charges,18.31,125.18,,,fee schedule,125.18% of custom fee schedule,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,14.78,100,,,fee schedule,Pays 100% Medicare OPPS,13.3,90,,,fee schedule,Pays 90% Medicare OPPS,29,58,,,percent of total billed charges,58% of total billed charges,17.61,120.37,,,fee schedule,120.37% of custom fee schedule,14.78,100,,,fee schedule,Pays 100% Medicare OPPS,19.21,130,,,fee schedule,Pays 130% Medicare OPPS,42.5,85,,,percent of total billed charges,85% of total billed charges,14.78,100,,,fee schedule,Pays 100% Medicare OPPS,13.3,45,
Manual urinalysis test with examination with or without using microscope,3081001,CDM,307,RC,81001,HCPCS,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,3.17,100,,,fee schedule,Pays 100% Medicare OPPS,3.17,100,,,fee schedule,Pays 100% Medicare OPPS,3.17,100,,,fee schedule,Pays 100% Medicare OPPS,4.12,130,,,fee schedule,Pays 130% Medicare OPPS,4.8,120.37,,,fee schedule,120.37% of custom fee schedule,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3.23,102,,,fee schedule,Pays 102% Medicare OPPS,45,90,,,percent of total billed charges,90% of total billed charges,4.99,125.18,,,fee schedule,125.18% of custom fee schedule,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,3.17,100,,,fee schedule,Pays 100% Medicare OPPS,2.85,90,,,fee schedule,Pays 90% Medicare OPPS,29,58,,,percent of total billed charges,58% of total billed charges,4.8,120.37,,,fee schedule,120.37% of custom fee schedule,3.17,100,,,fee schedule,Pays 100% Medicare OPPS,4.12,130,,,fee schedule,Pays 130% Medicare OPPS,42.5,85,,,percent of total billed charges,85% of total billed charges,3.17,100,,,fee schedule,Pays 100% Medicare OPPS,2.85,45,
.VOLUME MEASUREMENT 24HR,3081050,CDM,307,RC,81050,HCPCS,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,3.64,100,,,fee schedule,Pays 100% Medicare OPPS,3.64,100,,,fee schedule,Pays 100% Medicare OPPS,3.64,100,,,fee schedule,Pays 100% Medicare OPPS,4.73,130,,,fee schedule,Pays 130% Medicare OPPS,4.54,120.37,,,fee schedule,120.37% of custom fee schedule,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3.71,102,,,fee schedule,Pays 102% Medicare OPPS,45,90,,,percent of total billed charges,90% of total billed charges,4.72,125.18,,,fee schedule,125.18% of custom fee schedule,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,3.64,100,,,fee schedule,Pays 100% Medicare OPPS,3.27,90,,,fee schedule,Pays 90% Medicare OPPS,29,58,,,percent of total billed charges,58% of total billed charges,4.54,120.37,,,fee schedule,120.37% of custom fee schedule,3.64,100,,,fee schedule,Pays 100% Medicare OPPS,4.73,130,,,fee schedule,Pays 130% Medicare OPPS,42.5,85,,,percent of total billed charges,85% of total billed charges,3.64,100,,,fee schedule,Pays 100% Medicare OPPS,3.27,45,
GROUP B STREP ID,3087158,CDM,306,RC,87158,HCPCS,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,7.74,100,,,fee schedule,Pays 100% Medicare OPPS,7.74,100,,,fee schedule,Pays 100% Medicare OPPS,7.74,100,,,fee schedule,Pays 100% Medicare OPPS,10.06,130,,,fee schedule,Pays 130% Medicare OPPS,7.92,120.37,,,fee schedule,120.37% of custom fee schedule,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,7.89,102,,,fee schedule,Pays 102% Medicare OPPS,45,90,,,percent of total billed charges,90% of total billed charges,8.24,125.18,,,fee schedule,125.18% of custom fee schedule,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,7.74,100,,,fee schedule,Pays 100% Medicare OPPS,6.96,90,,,fee schedule,Pays 90% Medicare OPPS,29,58,,,percent of total billed charges,58% of total billed charges,7.92,120.37,,,fee schedule,120.37% of custom fee schedule,7.74,100,,,fee schedule,Pays 100% Medicare OPPS,10.06,130,,,fee schedule,Pays 130% Medicare OPPS,42.5,85,,,percent of total billed charges,85% of total billed charges,7.74,100,,,fee schedule,Pays 100% Medicare OPPS,6.96,45,
88300 SURGICAL PATHOLOGY LEVEL 1,3200005,CDM,310,RC,88300,HCPCS,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,22.19,100,,,fee schedule,Pays 100% Medicare OPPS,22.19,100,,,fee schedule,Pays 100% Medicare OPPS,22.19,100,,,fee schedule,Pays 100% Medicare OPPS,28.54,130,,,fee schedule,Pays 130% Medicare OPPS,17.21,120.37,,,fee schedule,120.37% of custom fee schedule,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.63,102,,,fee schedule,Pays 102% Medicare OPPS,45,90,,,percent of total billed charges,90% of total billed charges,17.9,125.18,,,fee schedule,125.18% of custom fee schedule,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,22.19,100,,,fee schedule,Pays 100% Medicare OPPS,19.97,90,,,fee schedule,Pays 90% Medicare OPPS,29,58,,,percent of total billed charges,58% of total billed charges,17.21,120.37,,,fee schedule,120.37% of custom fee schedule,21.95,100,,,fee schedule,Pays 100% Medicare OPPS,28.54,130,,,fee schedule,Pays 130% Medicare OPPS,42.5,85,,,percent of total billed charges,85% of total billed charges,22.19,100,,,fee schedule,Pays 100% Medicare OPPS,17.21,45,
88311 DECALCIFICATION PROCEDURE,3200011,CDM,310,RC,88311,HCPCS,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18.6,120.37,,,fee schedule,120.37% of custom fee schedule,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,19.34,125.18,,,fee schedule,125.18% of custom fee schedule,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,18.6,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,18.6,45,
"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",4377005,CDM,401,RC,77065,HCPCS,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,65,130,,,fee schedule,Pays 130% Medicare OPPS,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,51,102,,,fee schedule,Pays 102% Medicare OPPS,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,45,90,,,fee schedule,Pays 90% Medicare OPPS,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,50,100,,,fee schedule,Pays 100% Medicare OPPS,65,130,,,fee schedule,Pays 130% Medicare OPPS,42.5,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,10.19,65,
....MM CAD DIAGNOSTIC - BILATERAL,4377051,CDM,401,RC,G0206,HCPCS,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
Mammography of both breasts-2 or more views,4377052,CDM,403,RC,77067,HCPCS,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,65,130,,,fee schedule,Pays 130% Medicare OPPS,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,51,102,,,fee schedule,Pays 102% Medicare OPPS,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,45,90,,,fee schedule,Pays 90% Medicare OPPS,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,50,100,,,fee schedule,Pays 100% Medicare OPPS,65,130,,,fee schedule,Pays 130% Medicare OPPS,42.5,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,10.19,65,
PEAK FLOWMETER HS750,5550017,CDM,270,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
MEPILEX DRESSING,7901626,CDM,270,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
ASPIRATION SET,7905008,CDM,270,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
ANKLE STIRRUP AIR/GEL STAND 10 A152000,7905127,CDM,274,RC,L4350,HCPCS,Both,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
MORGAN TUBING,7905136,CDM,270,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
ANKLE BRACE LG,7905158,CDM,274,RC,L1902,HCPCS,Both,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
ANKLE BRACE SMALL,7905159,CDM,270,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
ANKLE BRACE MED(INCLUDES FIT/ADJ),7905160,CDM,274,RC,L1902,HCPCS,Both,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
ANKLE BRACE X-LG (INCLUDES FIT/ADJ),7905161,CDM,274,RC,L1902,HCPCS,Both,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
ABD BINDER 12 79-89091,7905166,CDM,270,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
ANKLE BRACE LG 7981097,7905251,CDM,274,RC,L1902,HCPCS,Both,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
KOTEX/STAYFREE REG.,7905260,CDM,270,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
ANKLE BRACE MD(INCLUDES FIT/ADJ) BRC6002,7905278,CDM,274,RC,L1902,HCPCS,Both,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
TUBING UTERINE ASPIRATING 00153,7905409,CDM,270,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
***DO NOT USE***,7905583,CDM,272,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
CAUTERY SURGICAL 55401,7905778,CDM,270,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
CAUTERY SURGICAL ESCT001,7905784,CDM,270,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
CAUTERY SURGICAL AA01,7905787,CDM,270,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
OP SITE 10 X 5 1/2,7905897,CDM,270,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,fee schedule,Pays 90% Medicare OPPS,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
OXYGEN/HR,7915407,CDM,270,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,fee schedule,Pays 90% Medicare OPPS,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
AMBU BAG ADULT,7915822,CDM,270,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,fee schedule,Pays 90% Medicare OPPS,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
VENT CIRCUIT,7919103,CDM,272,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,fee schedule,Pays 90% Medicare OPPS,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
OXYHOOD 4000,7919109,CDM,270,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,fee schedule,Pays 90% Medicare OPPS,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
OXYGEN PER HR,7919110,CDM,270,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,fee schedule,Pays 90% Medicare OPPS,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
SWIVEL ADAPTORS,7919210,CDM,270,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,fee schedule,Pays 90% Medicare OPPS,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
DRESSING MEPILEX 6 X 6,7950264,CDM,270,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,fee schedule,Pays 90% Medicare OPPS,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
DRESSING MEPILEX 4 X 4,7950267,CDM,270,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,fee schedule,Pays 90% Medicare OPPS,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
DRESSING KENDALL FOAM 6 X 6,7950276,CDM,272,RC,,,Outpatient,,,50,40,,42.5,85,,,percent of total billed charges,85% of total billed charges,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,12.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,percent of total billed charges,90% of total billed charges,17.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,34.35,68.7,,,percent of total billed charges,68.7% of total billed charges,40,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,45,90,,,fee schedule,Pays 90% Medicare OPPS,29,58,,,percent of total billed charges,58% of total billed charges,10.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.19,45,
CATH TRAY 16 FR. 6946,7905309,CDM,270,RC,,,Outpatient,,,52,41.6,,44.2,85,,,percent of total billed charges,85% of total billed charges,13,100,,,fee schedule,Pays 100% Medicare OPPS,13,100,,,fee schedule,Pays 100% Medicare OPPS,13,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,10.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,29.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,29.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,29.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,29.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,46.8,90,,,percent of total billed charges,90% of total billed charges,18.2,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,35.72,68.7,,,percent of total billed charges,68.7% of total billed charges,41.6,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,46.8,90,,,fee schedule,Pays 90% Medicare OPPS,30.16,58,,,percent of total billed charges,58% of total billed charges,10.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,44.2,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.59,46.8,
ANKLE BRACE SM(INCLUDES FIT/ADJ) BRC6001,7905280,CDM,274,RC,L1902,HCPCS,Both,,,53,42.4,,45.05,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,47.7,90,,,percent of total billed charges,90% of total billed charges,18.55,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,36.41,68.7,,,percent of total billed charges,68.7% of total billed charges,42.4,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,30.74,58,,,percent of total billed charges,58% of total billed charges,10.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,45.05,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.8,47.7,
ANKLE BRACE LG(INCLUDES FIT/ADJ) BRC6003,7905288,CDM,274,RC,L1902,HCPCS,Both,,,53,42.4,,45.05,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,47.7,90,,,percent of total billed charges,90% of total billed charges,18.55,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,36.41,68.7,,,percent of total billed charges,68.7% of total billed charges,42.4,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,30.74,58,,,percent of total billed charges,58% of total billed charges,10.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,45.05,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.8,47.7,
SUCTION SYSTEM CLOSED TURBO CLEANING,7905797,CDM,272,RC,,,Outpatient,,,53,42.4,,45.05,85,,,percent of total billed charges,85% of total billed charges,13.25,100,,,fee schedule,Pays 100% Medicare OPPS,13.25,100,,,fee schedule,Pays 100% Medicare OPPS,13.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,10.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,29.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,29.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,29.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,29.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,47.7,90,,,percent of total billed charges,90% of total billed charges,18.55,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,36.41,68.7,,,percent of total billed charges,68.7% of total billed charges,42.4,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,47.7,90,,,fee schedule,Pays 90% Medicare OPPS,30.74,58,,,percent of total billed charges,58% of total billed charges,10.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,45.05,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,10.8,47.7,
AIRWAY LMA SUPREME 2.5,1805011,CDM,272,RC,,,Outpatient,,,55,44,,46.75,85,,,percent of total billed charges,85% of total billed charges,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,11.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,49.5,90,,,percent of total billed charges,90% of total billed charges,19.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,37.79,68.7,,,percent of total billed charges,68.7% of total billed charges,44,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,49.5,90,,,fee schedule,Pays 90% Medicare OPPS,31.9,58,,,percent of total billed charges,58% of total billed charges,11.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,46.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,11.2,49.5,
AIRWAY LMA SUPREME 3,1805012,CDM,272,RC,,,Outpatient,,,55,44,,46.75,85,,,percent of total billed charges,85% of total billed charges,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,11.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,49.5,90,,,percent of total billed charges,90% of total billed charges,19.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,37.79,68.7,,,percent of total billed charges,68.7% of total billed charges,44,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,49.5,90,,,fee schedule,Pays 90% Medicare OPPS,31.9,58,,,percent of total billed charges,58% of total billed charges,11.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,46.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,11.2,49.5,
AIRWAY LMA SUPREME 4,1805013,CDM,272,RC,,,Outpatient,,,55,44,,46.75,85,,,percent of total billed charges,85% of total billed charges,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,11.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,49.5,90,,,percent of total billed charges,90% of total billed charges,19.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,37.79,68.7,,,percent of total billed charges,68.7% of total billed charges,44,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,49.5,90,,,fee schedule,Pays 90% Medicare OPPS,31.9,58,,,percent of total billed charges,58% of total billed charges,11.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,46.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,11.2,49.5,
AIRWAY LMA SUPREME 5,1805014,CDM,272,RC,,,Outpatient,,,55,44,,46.75,85,,,percent of total billed charges,85% of total billed charges,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,11.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,49.5,90,,,percent of total billed charges,90% of total billed charges,19.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,37.79,68.7,,,percent of total billed charges,68.7% of total billed charges,44,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,49.5,90,,,fee schedule,Pays 90% Medicare OPPS,31.9,58,,,percent of total billed charges,58% of total billed charges,11.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,46.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,11.2,49.5,
INDERAL (PROPRANOLOL) INJ 1MG/1ML,2600001,CDM,636,RC,J1800,HCPCS,Both,,,55,44,,46.75,85,,,percent of total billed charges,85% of total billed charges,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,9.63,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,49.5,90,,,percent of total billed charges,90% of total billed charges,10.01,125.18,,,fee schedule,125.18% of custom fee schedule,37.79,68.7,,,percent of total billed charges,68.7% of total billed charges,44,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,49.5,90,,,fee schedule,Pays 90% Medicare OPPS,31.9,58,,,percent of total billed charges,58% of total billed charges,9.63,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,46.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,9.63,49.5,
SOD NITROPRUSSIDE 50MG/2ML VIAL,2600124,CDM,250,RC,,,Outpatient,,,55,44,,46.75,85,,,percent of total billed charges,85% of total billed charges,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,11.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,49.5,90,,,percent of total billed charges,90% of total billed charges,19.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,37.79,68.7,,,percent of total billed charges,68.7% of total billed charges,44,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,49.5,90,,,fee schedule,Pays 90% Medicare OPPS,31.9,58,,,percent of total billed charges,58% of total billed charges,11.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,46.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,11.2,49.5,
PILOCAR 3% (PILOCARPINE) OPHT DROP,2600318,CDM,637,RC,,,Outpatient,,,55,44,,46.75,85,,,percent of total billed charges,85% of total billed charges,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,11.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,49.5,90,,,percent of total billed charges,90% of total billed charges,19.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,37.79,68.7,,,percent of total billed charges,68.7% of total billed charges,44,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,49.5,90,,,fee schedule,Pays 90% Medicare OPPS,31.9,58,,,percent of total billed charges,58% of total billed charges,11.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,46.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,11.2,49.5,
FAMVIR (FAMCICLOVIR) TAB 500MG,2602342,CDM,637,RC,,,Outpatient,,,55,44,,46.75,85,,,percent of total billed charges,85% of total billed charges,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,11.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,49.5,90,,,percent of total billed charges,90% of total billed charges,19.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,37.79,68.7,,,percent of total billed charges,68.7% of total billed charges,44,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,49.5,90,,,fee schedule,Pays 90% Medicare OPPS,31.9,58,,,percent of total billed charges,58% of total billed charges,11.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,46.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,11.2,49.5,
VANCOMYCIN 1500MG IV PREMIX,2610145,CDM,636,RC,,,Both,,,55,44,,46.75,85,,,percent of total billed charges,85% of total billed charges,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,11.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,49.5,90,,,percent of total billed charges,90% of total billed charges,19.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,37.79,68.7,,,percent of total billed charges,68.7% of total billed charges,44,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,49.5,90,,,fee schedule,Pays 90% Medicare OPPS,31.9,58,,,percent of total billed charges,58% of total billed charges,11.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,46.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,11.2,49.5,
**DO NOT USE**,7905633,CDM,272,RC,,,Outpatient,,,55,44,,46.75,85,,,percent of total billed charges,85% of total billed charges,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,11.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,49.5,90,,,percent of total billed charges,90% of total billed charges,19.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,37.79,68.7,,,percent of total billed charges,68.7% of total billed charges,44,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,49.5,90,,,fee schedule,Pays 90% Medicare OPPS,31.9,58,,,percent of total billed charges,58% of total billed charges,11.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,46.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,11.2,49.5,
NEEDLE ECHOGENIC STIMUPLEX ULTRA 360,7950311,CDM,272,RC,,,Outpatient,,,55,44,,46.75,85,,,percent of total billed charges,85% of total billed charges,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,13.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,11.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,49.5,90,,,percent of total billed charges,90% of total billed charges,19.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,37.79,68.7,,,percent of total billed charges,68.7% of total billed charges,44,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,49.5,90,,,fee schedule,Pays 90% Medicare OPPS,31.9,58,,,percent of total billed charges,58% of total billed charges,11.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,46.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,11.2,49.5,
Manual urinalysis test with examination without using microscope,300235,CDM,307,RC,81002,HCPCS,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,4.52,130,,,fee schedule,Pays 130% Medicare OPPS,3.86,120.37,,,fee schedule,120.37% of custom fee schedule,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3.54,102,,,fee schedule,Pays 102% Medicare OPPS,54,90,,,percent of total billed charges,90% of total billed charges,4.02,125.18,,,fee schedule,125.18% of custom fee schedule,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,3.13,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,3.86,120.37,,,fee schedule,120.37% of custom fee schedule,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,4.52,130,,,fee schedule,Pays 130% Medicare OPPS,51,85,,,percent of total billed charges,85% of total billed charges,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,3.13,54,
SUTURE 0 VICRYL JJ81G,1570516,CDM,272,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
SUTURE 1 VICRYL J335H,1570521,CDM,272,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
SUTURE 1 VICRYL J765D,1570522,CDM,272,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
SUTURE 2-0 CHROMIC U245H,1570523,CDM,272,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
SUTURE 3-0 PLAIN N862H,1570550,CDM,272,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
SUTURE 4-0 DEXON 7608-31,1570566,CDM,272,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
SUTURE 2-0 VICRYL VCP762D,1570643,CDM,272,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
SOD BICARBONATE 8.4% INJ 50MEQ,2600061,CDM,250,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
SOD BICARBONATE 4.2% INJ 5MEQ,2600062,CDM,636,RC,,,Both,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
TOPAMAX (TOPIRAMATE) TAB 100MG,2600127,CDM,637,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
ARICEPT (DONEPEZIL) TAB 10MG,2600163,CDM,637,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
PROCTOSOL-HC (HYDROCORT) 2.5% CRM 30GM,2600252,CDM,637,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
EYEWASH (COLLYRIUM) 4OZ SOLUTION,2600305,CDM,250,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
SILVADENE (SILVER SULFAD.)1% CRM 50GM,2600453,CDM,637,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
CLAFORAN (CEFOTAXIME NA) INJ : 500MG,2601001,CDM,636,RC,J0698,HCPCS,Both,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,11.8,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,12.27,125.18,,,fee schedule,125.18% of custom fee schedule,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,11.8,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,11.8,54,
BSS (BALANCED SALT SOLUTION) DROPS:15ML,2601289,CDM,637,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
XYLOCAINE 1% W/EPI (LIDO/EPI) VIAL 10ML,2601350,CDM,250,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
VANCOCIN (VANCOMYCIN) INJ 1GM,2601418,CDM,636,RC,J3370,HCPCS,Both,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.89,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,4.04,125.18,,,fee schedule,125.18% of custom fee schedule,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,3.89,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.89,54,
TORADOL (KETORALAC) INJ 30MG,2602844,CDM,636,RC,J1885,HCPCS,Both,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.77,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,0.8,125.18,,,fee schedule,125.18% of custom fee schedule,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,0.77,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.77,54,
ARICEPT (DONEPEZIL) TAB 5MG,2603088,CDM,637,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
VIGAMOX EYE DROPS (MOXIFLOXACIN) 3 ML,2605001,CDM,637,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
VALTREX (VALCYCLOVIR HCL) TAB 500MG,2605077,CDM,637,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
ACTOS (PIOGLITAZONE) TAB : 30MG,2605109,CDM,637,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
AVELOX (MOXIFLOXACIN) TAB : 400MG,2605132,CDM,637,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
MIDAZOLAM (VERSED) SYRUP 10MG/5ML,2660003,CDM,637,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
HUMALOG 75/25 10 ML,2660018,CDM,637,RC,J1815,HCPCS,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.59,120.37,,,fee schedule,120.37% of custom fee schedule,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,0.61,125.18,,,fee schedule,125.18% of custom fee schedule,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,0.59,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.59,54,
Manual urinalysis test with examination without using microscope,3000322,CDM,307,RC,81002,HCPCS,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,4.52,130,,,fee schedule,Pays 130% Medicare OPPS,3.86,120.37,,,fee schedule,120.37% of custom fee schedule,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3.54,102,,,fee schedule,Pays 102% Medicare OPPS,54,90,,,percent of total billed charges,90% of total billed charges,4.02,125.18,,,fee schedule,125.18% of custom fee schedule,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,3.13,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,3.86,120.37,,,fee schedule,120.37% of custom fee schedule,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,4.52,130,,,fee schedule,Pays 130% Medicare OPPS,51,85,,,percent of total billed charges,85% of total billed charges,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,3.13,54,
Manual urinalysis test with examination without using microscope,3000324,CDM,307,RC,81002,HCPCS,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,4.52,130,,,fee schedule,Pays 130% Medicare OPPS,3.86,120.37,,,fee schedule,120.37% of custom fee schedule,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3.54,102,,,fee schedule,Pays 102% Medicare OPPS,54,90,,,percent of total billed charges,90% of total billed charges,4.02,125.18,,,fee schedule,125.18% of custom fee schedule,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,3.13,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,3.86,120.37,,,fee schedule,120.37% of custom fee schedule,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,4.52,130,,,fee schedule,Pays 130% Medicare OPPS,51,85,,,percent of total billed charges,85% of total billed charges,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,3.13,54,
Manual urinalysis test with examination without using microscope,3000325,CDM,307,RC,81002,HCPCS,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,4.52,130,,,fee schedule,Pays 130% Medicare OPPS,3.86,120.37,,,fee schedule,120.37% of custom fee schedule,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3.54,102,,,fee schedule,Pays 102% Medicare OPPS,54,90,,,percent of total billed charges,90% of total billed charges,4.02,125.18,,,fee schedule,125.18% of custom fee schedule,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,3.13,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,3.86,120.37,,,fee schedule,120.37% of custom fee schedule,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,4.52,130,,,fee schedule,Pays 130% Medicare OPPS,51,85,,,percent of total billed charges,85% of total billed charges,3.48,100,,,fee schedule,Pays 100% Medicare OPPS,3.13,54,
3RD PH BODY FLUID NOT BLOOD,3000342,CDM,301,RC,83986,HCPCS,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,3.58,100,,,fee schedule,Pays 100% Medicare OPPS,3.58,100,,,fee schedule,Pays 100% Medicare OPPS,3.58,100,,,fee schedule,Pays 100% Medicare OPPS,4.65,130,,,fee schedule,Pays 130% Medicare OPPS,5.42,120.37,,,fee schedule,120.37% of custom fee schedule,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3.65,102,,,fee schedule,Pays 102% Medicare OPPS,54,90,,,percent of total billed charges,90% of total billed charges,5.63,125.18,,,fee schedule,125.18% of custom fee schedule,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,3.58,100,,,fee schedule,Pays 100% Medicare OPPS,3.22,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,5.42,120.37,,,fee schedule,120.37% of custom fee schedule,3.58,100,,,fee schedule,Pays 100% Medicare OPPS,4.65,130,,,fee schedule,Pays 130% Medicare OPPS,51,85,,,percent of total billed charges,85% of total billed charges,3.58,100,,,fee schedule,Pays 100% Medicare OPPS,3.22,54,
MOLECULAR DGN ISOL OR EXT (APOE),3000581,CDM,301,RC,83891,HCPCS,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
MOLECULAR DGN ENZYMATIC DIGESTION (APOE),3000582,CDM,301,RC,83892,HCPCS,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
MOLECULAR DGN NAP (APOE),3000583,CDM,301,RC,83896,HCPCS,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
MOLECULAR DGN AMP (APOE),3000584,CDM,301,RC,83908,HCPCS,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
MOLECULAR DGN I&R (APOE),3000585,CDM,301,RC,83912,HCPCS,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
.IMMUNOSSAY INFECTIOUS AGENT,3000688,CDM,301,RC,86317,HCPCS,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,14.99,100,,,fee schedule,Pays 100% Medicare OPPS,14.99,100,,,fee schedule,Pays 100% Medicare OPPS,14.99,100,,,fee schedule,Pays 100% Medicare OPPS,19.48,130,,,fee schedule,Pays 130% Medicare OPPS,18.16,120.37,,,fee schedule,120.37% of custom fee schedule,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.28,102,,,fee schedule,Pays 102% Medicare OPPS,54,90,,,percent of total billed charges,90% of total billed charges,18.89,125.18,,,fee schedule,125.18% of custom fee schedule,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,14.99,100,,,fee schedule,Pays 100% Medicare OPPS,13.49,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,18.16,120.37,,,fee schedule,120.37% of custom fee schedule,14.99,100,,,fee schedule,Pays 100% Medicare OPPS,19.48,130,,,fee schedule,Pays 130% Medicare OPPS,51,85,,,percent of total billed charges,85% of total billed charges,14.99,100,,,fee schedule,Pays 100% Medicare OPPS,13.49,54,
.BACTERIUM AB,3000735,CDM,301,RC,86609,HCPCS,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.13,102,,,fee schedule,Pays 102% Medicare OPPS,54,90,,,percent of total billed charges,90% of total billed charges,20.28,125.18,,,fee schedule,125.18% of custom fee schedule,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,51,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,54,
"ACETONE, SERUM",3082009,CDM,301,RC,82009,HCPCS,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,4.51,100,,,fee schedule,Pays 100% Medicare OPPS,4.51,100,,,fee schedule,Pays 100% Medicare OPPS,4.51,100,,,fee schedule,Pays 100% Medicare OPPS,5.87,130,,,fee schedule,Pays 130% Medicare OPPS,4.97,120.37,,,fee schedule,120.37% of custom fee schedule,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.61,102,,,fee schedule,Pays 102% Medicare OPPS,54,90,,,percent of total billed charges,90% of total billed charges,5.17,125.18,,,fee schedule,125.18% of custom fee schedule,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,4.51,100,,,fee schedule,Pays 100% Medicare OPPS,4.06,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,4.97,120.37,,,fee schedule,120.37% of custom fee schedule,4.51,100,,,fee schedule,Pays 100% Medicare OPPS,5.87,130,,,fee schedule,Pays 130% Medicare OPPS,51,85,,,percent of total billed charges,85% of total billed charges,4.51,100,,,fee schedule,Pays 100% Medicare OPPS,4.06,54,
"BB BLOOD TYPE, ABO",3086900,CDM,300,RC,86900,HCPCS,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,4.51,120.37,,,fee schedule,120.37% of custom fee schedule,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,54,90,,,percent of total billed charges,90% of total billed charges,4.69,125.18,,,fee schedule,125.18% of custom fee schedule,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,4.51,120.37,,,fee schedule,120.37% of custom fee schedule,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,51,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,4.51,132.76,
PT STUDENT-TEACHER CONFERENCE,5000002,CDM,424,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
POLYP TRAP,7905051,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
STOMACH EVACUATOR TUBE,7905118,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
SWEET EASE SUCROSE SOLN,7905151,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
CATH 16 FR. PP16SD,7905173,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
CATH 18 FR. PP18SD DYND11520,7905174,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
ICE PACK LARGE,7905178,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
CATH TRAY 16 FR. DYND11519,7905179,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
CATH TRAY 18 FR.,7905180,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
CLAVICLE BRACE MEDIUM (FIT/ADJ),7905204,CDM,274,RC,L3671,HCPCS,Both,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
CLAVICLE BRACE SMALL(fitting/adj),7905216,CDM,274,RC,L3650,HCPCS,Both,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
CLAVICLE BRACE XLG (FIT/ADJ),7905218,CDM,274,RC,L3671,HCPCS,Both,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
CATH TRAY 16 FR. 897516,7905222,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
CATH TRAY 18 FR. 897518,7905223,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
CATH TRAY 16 FR. 3716,7905227,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
CATH TRAY 18 FR. DYND11528,7905241,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
CATH TRAY 16 FR. DYND11523,7905244,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
MATERNITY KIT,7905269,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
CATH TRAY 16 FR. 300416A,7905291,CDM,272,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
CATH TRAY 16 FR. 899916,7905293,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
CATH TRAY 18 FR. 899918,7905294,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
CATH TRAY 16 FR. 947316,7905295,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
CATH TRAY 18 FR. 947318,7905297,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
HUGGIES SMALL,7905298,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
CATH TRAY 16 FR. 6140,7905299,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
CATH TRAY 18 FR. 6210,7905300,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
CATH TRAY 16 FR. 6014,7905301,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
CATH TRAY 16 FR. A947316,7905305,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
SIGMOID SUCTION SET,7905332,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
LUMBAR PUN TRAY PED 945,7905414,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
EAR WICK,7905492,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
SURGICAL SUCTION TUBE 35050,7905688,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
LECTROVAC II 10 FR FOOT,7905781,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
PUTTY COLOR CHANGE C92519,7907178,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
SPLINT TOE ALL SIZE,7907530,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
OXISENSOR N25,7915408,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
OXIMETER SENSOR PULSE NEONATAL,7915409,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
OXIMETER SENSOR PULSE ADULT LNCS ADTX,7915410,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
OXIMETER SENSOR PULSE ADULT 18IN,7915411,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
VENTURI MASK ADULT 1088,7919105,CDM,270,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
**DO NOT USE**,7950010,CDM,272,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
TUBING HIGH FLOW ASPIRATION LF STERILE,7950342,CDM,272,RC,,,Outpatient,,,60,48,,51,85,,,percent of total billed charges,85% of total billed charges,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,15,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,percent of total billed charges,90% of total billed charges,21,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,41.22,68.7,,,percent of total billed charges,68.7% of total billed charges,48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,54,90,,,fee schedule,Pays 90% Medicare OPPS,34.8,58,,,percent of total billed charges,58% of total billed charges,12.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.22,54,
SUTURE 0 VICRYL J603H,1570514,CDM,272,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
SUTURE 2-0 CHROMIC L113G,1570526,CDM,272,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
SUTURE 3-0 VICRYL J980J,1570556,CDM,272,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
SUTURE 4-0 VICRYL J214H,1570578,CDM,272,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
SUTURE 4-0 VICRYL J392H,1570584,CDM,272,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
SUTURE 0 PROLENE C821G,1570600,CDM,272,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
TOURNIQUET CUFF 18IN STERILE,1570840,CDM,272,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
TOURNIQUET CUFF 24IN STERILE,1570841,CDM,272,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
TOURNIQUET CUFF 30IN STERILE,1570842,CDM,272,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
TOURNIQUET CUFF 34IN STERILE,1570843,CDM,272,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
TOURNIQUET CUFF 42IN STERILE,1570844,CDM,272,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES PROCS EAR UNSPEC,1800120,CDM,379,RC,120,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES OTOSCOPY,1800124,CDM,379,RC,124,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES TYPANATOMY,1800126,CDM,379,RC,126,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES EYE NOT OTHWS SPECIF,1800140,CDM,379,RC,140,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES CATARACT LENS SURGER,1800142,CDM,379,RC,142,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES NOSE SINUSES UNSPECI,1800160,CDM,379,RC,160,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES INTRAORAL TONSILS AD,1800170,CDM,379,RC,170,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES MUSC NERVES HEAD NEC,1800300,CDM,379,RC,300,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.53,56.2,,,percent of total billed charges,56.5 percent of total billed charges,36.53,56.2,,,percent of total billed charges,56.5 percent of total billed charges,36.53,56.2,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.2,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES NECK UNSPEC,1800320,CDM,379,RC,320,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES INTEG SYSTEM UNSPEC,1800400,CDM,379,RC,400,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES RADICAL/MODIFIED PROC ON BREAST,1800404,CDM,379,RC,450,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES ELECTRICAL CONVERSION,1800410,CDM,379,RC,410,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES CLAVICLE/SCAPULA/UNS,1800450,CDM,379,RC,450,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES PERMANENT TRANSVENOUS PACEMAKER INS,1800530,CDM,379,RC,530,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES ACCESS CENTRAL VENOUS CIRCULATION,1800532,CDM,379,RC,532,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES UPPER POST ABD WALL,1800730,CDM,379,RC,730,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES UPPER GASTROINTESTIONAL,1800740,CDM,379,RC,740,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES HERNIA UPP ABD UNSPE,1800750,CDM,379,RC,750,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES WOUND DEHISCENCE LUM,1800752,CDM,379,RC,752,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES INTROPERIT LAP,1800790,CDM,379,RC,790,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES LOWER ENDOSCOPIC PRO,1800810,CDM,379,RC,810,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES HERNIA LOW ABD UNSPE,1800830,CDM,379,RC,830,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES INTROPER LOW ABD UNS,1800840,CDM,379,RC,840,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES TUBAL LIGATION/TRANS,1800851,CDM,379,RC,851,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES PROCEDURE LOWER ABDOMEN,1800860,CDM,379,RC,860,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES PERINEAL INTEG SYSTE,1800902,CDM,379,RC,902,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES PROCS ON MALE GENITA,1800920,CDM,379,RC,920,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES VAGINAL PROC UNSPEC,1800940,CDM,379,RC,940,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES COLPOTOMY VAGINECTOM,1800942,CDM,379,RC,942,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES VAGINAL HYSTERECTOMY,1800944,CDM,379,RC,944,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES HYSTEROSCOPY OR HYST,1800952,CDM,379,RC,952,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES OPEN PROC RADICAL RE,1801234,CDM,379,RC,1234,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,65,100,,,fee schedule,Pays 100% Medicare OPPS,65,100,,,fee schedule,Pays 100% Medicare OPPS,65,100,,,fee schedule,Pays 100% Medicare OPPS,65,130,,,fee schedule,Pays 130% Medicare OPPS,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,65,102,,,fee schedule,Pays 102% Medicare OPPS,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,65,100,,,fee schedule,Pays 100% Medicare OPPS,65,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,65,100,,,fee schedule,Pays 100% Medicare OPPS,65,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,65,100,,,fee schedule,Pays 100% Medicare OPPS,13.24,65,
ANES PROCEDURE UPPER LEG,1801250,CDM,379,RC,1250,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES PROCEDURE KNEE & POPLITEAL AREA,1801320,CDM,379,RC,1320,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES OPEN PROC LOW FEMUR,1801360,CDM,379,RC,1360,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES CLOSE PROC KNEE JOIN,1801380,CDM,379,RC,1380,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES ARTHROSCOPE KNEE,1801382,CDM,379,RC,1382,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES OPEN/SURG ARTHRO KNE,1801400,CDM,379,RC,1400,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES CLOSED LOWER LEG,1801462,CDM,379,RC,1462,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES NERVES MUSCLES TENDO,1801470,CDM,379,RC,1470,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES RPR ACHILLES TENDON,1801472,CDM,379,RC,1472,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES BONES PODIATRY,1801480,CDM,379,RC,1480,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES SHOULDER NERVES MUS,1801610,CDM,379,RC,1610,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES ARTHRO SHOULDER JOIN,1801630,CDM,379,RC,1630,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES NERVES MUSCLES TENDO,1801710,CDM,379,RC,1710,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES ARHTRO PROC ELBOW,1801740,CDM,379,RC,1740,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES FOREARM WRIST AND HA,1801810,CDM,379,RC,1810,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES CLSD PROC RADIUS ULN,1801820,CDM,379,RC,1820,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES OPEN PROC RADIUS ULN,1801830,CDM,379,RC,1830,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
Anesthesia for cesarean delivery,1801961,CDM,379,RC,1961,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
ANES FOR INCOMPLETE/MISSED ABORTION PROC,1801964,CDM,379,RC,1965,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
Anesthesia for cesarean delivery following labor,1801968,CDM,379,RC,1968,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,13.24,58.5,
XYLOCAINE 2% (LIDOCAINE) UROJET 5ML,2600015,CDM,636,RC,J2001,HCPCS,Both,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.02,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,0.03,125.18,,,fee schedule,125.18% of custom fee schedule,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,0.02,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.02,58.5,
ERYTHROCIN (ERYTHROMYCIN LAC) INJ 500MG,2600040,CDM,636,RC,J1364,HCPCS,Both,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,108.73,130,,,fee schedule,Pays 130% Medicare OPPS,99.79,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,103.77,125.18,,,fee schedule,125.18% of custom fee schedule,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,99.79,120.37,,,fee schedule,120.37% of custom fee schedule,83.64,100,,,fee schedule,Pays 100% Medicare OPPS,108.73,130,,,fee schedule,Pays 130% Medicare OPPS,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,16.25,108.73,
CLINDAMYCIN 900MG/6ML VIAL,2600180,CDM,250,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
PILOCAR 2% (PILOCARPINE) OPHT DROP,2600317,CDM,637,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
PILOCAR 4% (PILOCARPINE) OPHT DROP,2600319,CDM,637,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
GARAMYCIN (GENTAMICIN SULF)0.3% OPH DROP,2600340,CDM,637,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
BENZOIN TINCTURE SPRAY,2600403,CDM,637,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
MORPHINE SULF INJ 2MG,2601166,CDM,636,RC,J2270,HCPCS,Both,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.57,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,3.72,125.18,,,fee schedule,125.18% of custom fee schedule,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,3.57,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.57,58.5,
MORPHINE SULF INJ 4MG,2601167,CDM,636,RC,J2270,HCPCS,Both,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.57,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,3.72,125.18,,,fee schedule,125.18% of custom fee schedule,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,3.57,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.57,58.5,
KETALAR (KETAMINE) INJ 500MG,2601303,CDM,250,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
LOPRESSOR (METOPROLOL) INJ 5MG,2601347,CDM,250,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
REGLAN (METOCLOPRAMIDE HCL) INJ 10MG,2601386,CDM,636,RC,J2765,HCPCS,Both,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,1.28,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,1.33,125.18,,,fee schedule,125.18% of custom fee schedule,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,1.28,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1.28,58.5,
ZOFRAN (ONDANSETRON HCL) INJ 4MG,2601408,CDM,636,RC,J2405,HCPCS,Both,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.11,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,0.11,125.18,,,fee schedule,125.18% of custom fee schedule,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,0.11,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.11,58.5,
CYCLOGYL (CYCLOPENTOLATE)OPHTH DROP (OR),2602226,CDM,250,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
MORPHINE SULF INJ 10MG,2602229,CDM,636,RC,J2270,HCPCS,Both,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.57,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,3.72,125.18,,,fee schedule,125.18% of custom fee schedule,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,3.57,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.57,58.5,
NF-PROMETHAZINE (PHENERGAN) INJ 50MG,2602772,CDM,636,RC,J2550,HCPCS,Both,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.54,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,3.68,125.18,,,fee schedule,125.18% of custom fee schedule,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,3.54,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.54,58.5,
NF-STERAPRED DS DOSEPAK 10MG,2602778,CDM,637,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
MUCOMYST 20% ORAL SOL 30ML,2605015,CDM,250,RC,J7608,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
TRANS-SCOP (SCOPOLAMINE) PATCH 1.5MG,2605082,CDM,637,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
IV FILTER SET 1.2MIC MIS,2610054,CDM,270,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
MULTIVITAMIN-12 INJ 10ML,2610056,CDM,250,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
LOVENOX (ENOXAPARIN) INJ 80MG,2660000,CDM,636,RC,J1650,HCPCS,Both,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
MOLECULAR DGN ENZ (C FG X,3000203,CDM,301,RC,83892,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
MOLECULAR DGN SEP (C FG X,3000205,CDM,301,RC,83894,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
MOLECULAR DIAG (C FRAG X),3000206,CDM,301,RC,83890,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
"MOLECULAR DIAG,DOT/SLOT B",3000214,CDM,301,RC,83893,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
"MOLECULAR DIAG,ISO/EX PNA",3000215,CDM,301,RC,83891,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
YEAST ID,3000336,CDM,306,RC,87102,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,8.41,100,,,fee schedule,Pays 100% Medicare OPPS,8.41,100,,,fee schedule,Pays 100% Medicare OPPS,8.41,100,,,fee schedule,Pays 100% Medicare OPPS,10.93,130,,,fee schedule,Pays 130% Medicare OPPS,12.72,120.37,,,fee schedule,120.37% of custom fee schedule,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.57,102,,,fee schedule,Pays 102% Medicare OPPS,58.5,90,,,percent of total billed charges,90% of total billed charges,13.23,125.18,,,fee schedule,125.18% of custom fee schedule,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,8.41,100,,,fee schedule,Pays 100% Medicare OPPS,7.56,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,12.72,120.37,,,fee schedule,120.37% of custom fee schedule,8.41,100,,,fee schedule,Pays 100% Medicare OPPS,10.93,130,,,fee schedule,Pays 130% Medicare OPPS,55.25,85,,,percent of total billed charges,85% of total billed charges,8.41,100,,,fee schedule,Pays 100% Medicare OPPS,7.56,58.5,
Test of a wound for type of bacterial infection,3000350,CDM,306,RC,87077,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,8.08,100,,,fee schedule,Pays 100% Medicare OPPS,8.08,100,,,fee schedule,Pays 100% Medicare OPPS,8.08,100,,,fee schedule,Pays 100% Medicare OPPS,10.5,130,,,fee schedule,Pays 130% Medicare OPPS,12.23,120.37,,,fee schedule,120.37% of custom fee schedule,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.24,102,,,fee schedule,Pays 102% Medicare OPPS,58.5,90,,,percent of total billed charges,90% of total billed charges,12.72,125.18,,,fee schedule,125.18% of custom fee schedule,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,8.08,100,,,fee schedule,Pays 100% Medicare OPPS,7.27,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,12.23,120.37,,,fee schedule,120.37% of custom fee schedule,8.08,100,,,fee schedule,Pays 100% Medicare OPPS,10.5,130,,,fee schedule,Pays 130% Medicare OPPS,55.25,85,,,percent of total billed charges,85% of total billed charges,8.08,100,,,fee schedule,Pays 100% Medicare OPPS,7.27,58.5,
MOLECULAR DGN NAP (C FG X,3083896,CDM,301,RC,83896,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
MOLECULAR DGN NAT (C FG X,3083897,CDM,301,RC,83897,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
"MOLECULAR DIAG AMP PNA,MU",3083901,CDM,301,RC,83901,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
MOLECULAR DGN I&R (C FG X,3083912,CDM,301,RC,83912,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
ANAEROBIC IDENTIFICATION,3087076,CDM,306,RC,87076,HCPCS,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,8.08,100,,,fee schedule,Pays 100% Medicare OPPS,8.08,100,,,fee schedule,Pays 100% Medicare OPPS,8.08,100,,,fee schedule,Pays 100% Medicare OPPS,10.5,130,,,fee schedule,Pays 130% Medicare OPPS,12.23,120.37,,,fee schedule,120.37% of custom fee schedule,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.24,102,,,fee schedule,Pays 102% Medicare OPPS,58.5,90,,,percent of total billed charges,90% of total billed charges,12.72,125.18,,,fee schedule,125.18% of custom fee schedule,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,8.08,100,,,fee schedule,Pays 100% Medicare OPPS,7.27,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,12.23,120.37,,,fee schedule,120.37% of custom fee schedule,8.08,100,,,fee schedule,Pays 100% Medicare OPPS,10.5,130,,,fee schedule,Pays 130% Medicare OPPS,55.25,85,,,percent of total billed charges,85% of total billed charges,8.08,100,,,fee schedule,Pays 100% Medicare OPPS,7.27,58.5,
MUCOUS TRAP DYND44110,5550030,CDM,270,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
AMBU BAG CHILD,7900002,CDM,270,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
VENTURI MASK PED,7900003,CDM,270,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
NON-REBREATHING MASK PED. HOSPITAK,7900004,CDM,270,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
URINE LEG BAG LB0019,7905061,CDM,270,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
NU-GAUZE PLAIN 1/4,7905066,CDM,270,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
CLAVICLE BRACE XS (FIT/ADJ),7905219,CDM,274,RC,L3650,HCPCS,Both,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
FLOWTRON GARMENT,7905284,CDM,270,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
RESTRAINT VEST 3311M,7905311,CDM,270,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
RESTRAINT VEST M228-M,7905312,CDM,270,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
GROUNDING PAD 607202002,7905563,CDM,270,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
***DO NOT USE***,7905589,CDM,272,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
**DO NOT USE**,7905632,CDM,272,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
SUTURE O CHROMIC L114G,7905635,CDM,272,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
SUTURE 5-0 DEXON 7608-21,7905638,CDM,272,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
DRESSING NASAL 4.5 CM,7905954,CDM,272,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
NASAL RHINO ROCKET SLIMLINE MED,7905959,CDM,272,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
CO2 DETECTOR EASYCAP II,7915429,CDM,270,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
CO2 DETECTOR PEDICAP II,7915430,CDM,270,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
CURAGEL DRESSINGS,7950118,CDM,270,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
CORDBIP FORCEPS E0509,7950174,CDM,270,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
BREAST PUMP,7950220,CDM,270,RC,,,Outpatient,,,65,52,,55.25,85,,,percent of total billed charges,85% of total billed charges,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,percent of total billed charges,90% of total billed charges,22.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44.66,68.7,,,percent of total billed charges,68.7% of total billed charges,52,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,58.5,90,,,fee schedule,Pays 90% Medicare OPPS,37.7,58,,,percent of total billed charges,58% of total billed charges,13.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.24,58.5,
TUBING 13FT SOFTOUCH INFILTRATION,7950343,CDM,272,RC,,,Outpatient,,,66,52.8,,56.1,85,,,percent of total billed charges,85% of total billed charges,16.5,100,,,fee schedule,Pays 100% Medicare OPPS,16.5,100,,,fee schedule,Pays 100% Medicare OPPS,16.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,13.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,37.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,37.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,37.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,37.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,59.4,90,,,percent of total billed charges,90% of total billed charges,23.1,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,45.34,68.7,,,percent of total billed charges,68.7% of total billed charges,52.8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,59.4,90,,,fee schedule,Pays 90% Medicare OPPS,38.28,58,,,percent of total billed charges,58% of total billed charges,13.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,56.1,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.44,59.4,
SUTURE 10-0 ETHILON 9061G,1570580,CDM,272,RC,,,Outpatient,,,70,56,,59.5,85,,,percent of total billed charges,85% of total billed charges,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,63,90,,,percent of total billed charges,90% of total billed charges,24.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,48.09,68.7,,,percent of total billed charges,68.7% of total billed charges,56,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,63,90,,,fee schedule,Pays 90% Medicare OPPS,40.6,58,,,percent of total billed charges,58% of total billed charges,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,59.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,14.26,63,
SUTURE 8-0 VICRYL J548G,1570599,CDM,272,RC,,,Outpatient,,,70,56,,59.5,85,,,percent of total billed charges,85% of total billed charges,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,63,90,,,percent of total billed charges,90% of total billed charges,24.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,48.09,68.7,,,percent of total billed charges,68.7% of total billed charges,56,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,63,90,,,fee schedule,Pays 90% Medicare OPPS,40.6,58,,,percent of total billed charges,58% of total billed charges,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,59.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,14.26,63,
DRAIN 15FR CHANNEL ROUND HUBLESS,1570802,CDM,272,RC,,,Outpatient,,,70,56,,59.5,85,,,percent of total billed charges,85% of total billed charges,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,63,90,,,percent of total billed charges,90% of total billed charges,24.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,48.09,68.7,,,percent of total billed charges,68.7% of total billed charges,56,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,63,90,,,fee schedule,Pays 90% Medicare OPPS,40.6,58,,,percent of total billed charges,58% of total billed charges,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,59.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,14.26,63,
Preservative free flu vaccine,2600076,CDM,636,RC,90658,HCPCS,Both,,,70,56,,59.5,85,,,percent of total billed charges,85% of total billed charges,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63,90,,,percent of total billed charges,90% of total billed charges,24.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,48.09,68.7,,,percent of total billed charges,68.7% of total billed charges,56,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,63,90,,,fee schedule,Pays 90% Medicare OPPS,40.6,58,,,percent of total billed charges,58% of total billed charges,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,59.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,14.26,63,
TYMPAGESIC (BENZ/PHENTIPYR) OTIC,2600106,CDM,637,RC,,,Outpatient,,,70,56,,59.5,85,,,percent of total billed charges,85% of total billed charges,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,63,90,,,percent of total billed charges,90% of total billed charges,24.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,48.09,68.7,,,percent of total billed charges,68.7% of total billed charges,56,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,63,90,,,fee schedule,Pays 90% Medicare OPPS,40.6,58,,,percent of total billed charges,58% of total billed charges,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,59.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,14.26,63,
PRED FORTE (PREDNISOLONE) 1% OPHT DROP,2600311,CDM,637,RC,,,Outpatient,,,70,56,,59.5,85,,,percent of total billed charges,85% of total billed charges,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,63,90,,,percent of total billed charges,90% of total billed charges,24.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,48.09,68.7,,,percent of total billed charges,68.7% of total billed charges,56,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,63,90,,,fee schedule,Pays 90% Medicare OPPS,40.6,58,,,percent of total billed charges,58% of total billed charges,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,59.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,14.26,63,
XYLOCAINE 1% (LIDOCAINE) VIAL: 20ML,2603005,CDM,636,RC,,,Both,,,70,56,,59.5,85,,,percent of total billed charges,85% of total billed charges,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63,90,,,percent of total billed charges,90% of total billed charges,24.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,48.09,68.7,,,percent of total billed charges,68.7% of total billed charges,56,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,63,90,,,fee schedule,Pays 90% Medicare OPPS,40.6,58,,,percent of total billed charges,58% of total billed charges,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,59.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,14.26,63,
MORPHINE (DURAMORPH) 0.5MG/1ML 10ML AMP,2603013,CDM,636,RC,J2270,HCPCS,Both,,,70,56,,59.5,85,,,percent of total billed charges,85% of total billed charges,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.57,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63,90,,,percent of total billed charges,90% of total billed charges,3.72,125.18,,,fee schedule,125.18% of custom fee schedule,48.09,68.7,,,percent of total billed charges,68.7% of total billed charges,56,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,63,90,,,fee schedule,Pays 90% Medicare OPPS,40.6,58,,,percent of total billed charges,58% of total billed charges,3.57,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,59.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.57,63,
CARDENE (NICARDIPINE) INJ 25MG,2610125,CDM,250,RC,,,Outpatient,,,70,56,,59.5,85,,,percent of total billed charges,85% of total billed charges,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,63,90,,,percent of total billed charges,90% of total billed charges,24.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,48.09,68.7,,,percent of total billed charges,68.7% of total billed charges,56,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,63,90,,,fee schedule,Pays 90% Medicare OPPS,40.6,58,,,percent of total billed charges,58% of total billed charges,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,59.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,14.26,63,
ADMIN 1ST MODERNA DOSE COVID19 VACCINE,2611111,CDM,771,RC,0011A,HCPCS,Outpatient,,,70,56,,59.5,85,,,percent of total billed charges,85% of total billed charges,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,35.88,102,,,fee schedule,Pays 102% Medicare OPPS,63,90,,,percent of total billed charges,90% of total billed charges,24.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,48.09,68.7,,,percent of total billed charges,68.7% of total billed charges,56,80,,,percent of total billed charges,80 percent of total billed charges,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,31.66,90,,,fee schedule,Pays 90% Medicare OPPS,40.6,58,,,percent of total billed charges,58% of total billed charges,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,14.26,63,
RC RH TYPE,3008690,CDM,300,RC,86901,HCPCS,Outpatient,,,70,56,,59.5,85,,,percent of total billed charges,85% of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,38.83,130,,,fee schedule,Pays 130% Medicare OPPS,17.47,120.37,,,fee schedule,120.37% of custom fee schedule,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.01,102,,,fee schedule,Pays 102% Medicare OPPS,63,90,,,percent of total billed charges,90% of total billed charges,18.16,125.18,,,fee schedule,125.18% of custom fee schedule,48.09,68.7,,,percent of total billed charges,68.7% of total billed charges,56,80,,,percent of total billed charges,80 percent of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,27.36,90,,,fee schedule,Pays 90% Medicare OPPS,40.6,58,,,percent of total billed charges,58% of total billed charges,17.47,120.37,,,fee schedule,120.37% of custom fee schedule,29.87,100,,,fee schedule,Pays 100% Medicare OPPS,38.83,130,,,fee schedule,Pays 130% Medicare OPPS,59.5,85,,,percent of total billed charges,85% of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,17.47,63,
MOLECULAR DGN MUT BY TRAN,3083905,CDM,300,RC,83905,HCPCS,Outpatient,,,70,56,,59.5,85,,,percent of total billed charges,85% of total billed charges,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,63,90,,,percent of total billed charges,90% of total billed charges,24.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,48.09,68.7,,,percent of total billed charges,68.7% of total billed charges,56,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,63,90,,,fee schedule,Pays 90% Medicare OPPS,40.6,58,,,percent of total billed charges,58% of total billed charges,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,59.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,14.26,63,
RC RBC ANTIGENS other THAN ABO/RH(D) (RC,3086905,CDM,300,RC,86905,HCPCS,Outpatient,,,70,56,,59.5,85,,,percent of total billed charges,85% of total billed charges,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,370.6,130,,,fee schedule,Pays 130% Medicare OPPS,5.79,120.37,,,fee schedule,120.37% of custom fee schedule,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,266.86,102,,,fee schedule,Pays 102% Medicare OPPS,63,90,,,percent of total billed charges,90% of total billed charges,6.02,125.18,,,fee schedule,125.18% of custom fee schedule,48.09,68.7,,,percent of total billed charges,68.7% of total billed charges,56,80,,,percent of total billed charges,80 percent of total billed charges,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,235.46,90,,,fee schedule,Pays 90% Medicare OPPS,40.6,58,,,percent of total billed charges,58% of total billed charges,5.79,120.37,,,fee schedule,120.37% of custom fee schedule,285.08,100,,,fee schedule,Pays 100% Medicare OPPS,370.6,130,,,fee schedule,Pays 130% Medicare OPPS,59.5,85,,,percent of total billed charges,85% of total billed charges,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,5.79,370.6,
ANKLE BRACE NORCO AIR CELL(FIT/ADJUST),7905125,CDM,274,RC,L4350,HCPCS,Both,,,70,56,,59.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63,90,,,percent of total billed charges,90% of total billed charges,24.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,48.09,68.7,,,percent of total billed charges,68.7% of total billed charges,56,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,40.6,58,,,percent of total billed charges,58% of total billed charges,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,59.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,14.26,63,
ANKLE STIRRUP AIR STANDARD 10 1172PP,7905126,CDM,274,RC,L4350,HCPCS,Both,,,70,56,,59.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63,90,,,percent of total billed charges,90% of total billed charges,24.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,48.09,68.7,,,percent of total billed charges,68.7% of total billed charges,56,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,40.6,58,,,percent of total billed charges,58% of total billed charges,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,59.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,14.26,63,
SUCTION COAGULATOR E3310,7905782,CDM,270,RC,,,Outpatient,,,70,56,,59.5,85,,,percent of total billed charges,85% of total billed charges,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,63,90,,,percent of total billed charges,90% of total billed charges,24.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,48.09,68.7,,,percent of total billed charges,68.7% of total billed charges,56,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,63,90,,,fee schedule,Pays 90% Medicare OPPS,40.6,58,,,percent of total billed charges,58% of total billed charges,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,59.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,14.26,63,
SUCTION COAGULATOR 250510-FR,7905783,CDM,272,RC,,,Outpatient,,,70,56,,59.5,85,,,percent of total billed charges,85% of total billed charges,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,63,90,,,percent of total billed charges,90% of total billed charges,24.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,48.09,68.7,,,percent of total billed charges,68.7% of total billed charges,56,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,63,90,,,fee schedule,Pays 90% Medicare OPPS,40.6,58,,,percent of total billed charges,58% of total billed charges,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,59.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,14.26,63,
DRESSING NASAL 8 CM,7905955,CDM,272,RC,,,Outpatient,,,70,56,,59.5,85,,,percent of total billed charges,85% of total billed charges,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,63,90,,,percent of total billed charges,90% of total billed charges,24.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,48.09,68.7,,,percent of total billed charges,68.7% of total billed charges,56,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,63,90,,,fee schedule,Pays 90% Medicare OPPS,40.6,58,,,percent of total billed charges,58% of total billed charges,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,59.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,14.26,63,
ENDOPATH BLUNT TIP DISSECTOR BTD05,7950171,CDM,272,RC,,,Outpatient,,,70,56,,59.5,85,,,percent of total billed charges,85% of total billed charges,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,17.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,63,90,,,percent of total billed charges,90% of total billed charges,24.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,48.09,68.7,,,percent of total billed charges,68.7% of total billed charges,56,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,63,90,,,fee schedule,Pays 90% Medicare OPPS,40.6,58,,,percent of total billed charges,58% of total billed charges,14.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,59.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,14.26,63,
BREATHING CIRCUIT ADLT SINGLE LIMB HEAT,7950312,CDM,270,RC,,,Outpatient,,,71,56.8,,60.35,85,,,percent of total billed charges,85% of total billed charges,17.75,100,,,fee schedule,Pays 100% Medicare OPPS,17.75,100,,,fee schedule,Pays 100% Medicare OPPS,17.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,14.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,40.12,56.5,,,percent of total billed charges,56.5 percent of total billed charges,40.12,56.5,,,percent of total billed charges,56.5 percent of total billed charges,40.12,56.5,,,percent of total billed charges,56.5 percent of total billed charges,40.12,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,63.9,90,,,percent of total billed charges,90% of total billed charges,24.85,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,48.78,68.7,,,percent of total billed charges,68.7% of total billed charges,56.8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,63.9,90,,,fee schedule,Pays 90% Medicare OPPS,41.18,58,,,percent of total billed charges,58% of total billed charges,14.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,60.35,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,14.46,63.9,
SUTURE 1 VICRYL J261H,1570520,CDM,272,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
SUTURE 2-0 PLAIN L103G,1570528,CDM,272,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
SUTURE 2-0 PLAIN N863H,1570529,CDM,272,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
SUTURE 3-0 VICRYL J423H,1570561,CDM,272,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
SUTURE 5-0 PROLENE 9702H,1570638,CDM,272,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
SPINAL ANES TRAY P25BK,1805001,CDM,270,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
CAPNOLINE O2 0683-00-0496-25,2092964,CDM,270,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
XYLOCAINE 2% (LIDOCAINE) JELLY 5ML,2600070,CDM,250,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
NON-FORMULARY SUPP,2600098,CDM,637,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
CLEOCIN 300MG/50ML IVPB PREMIX,2600113,CDM,250,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
PROPINE (DIPIVEFRIN) 0.1% OPHTH SOL,2600321,CDM,250,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
DERMABOND ADVANCED,2600554,CDM,270,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
LASIX (FUROSEMIDE) LIQ 10MG,2600842,CDM,637,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
DEMEROL (MEPERIDINE HCL) INJ 50MG,2601152,CDM,636,RC,J2175,HCPCS,Both,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.21,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,7.5,125.18,,,fee schedule,125.18% of custom fee schedule,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,7.21,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.21,67.5,
DEMEROL (MEPERIDINE HCL) INJ 100MG,2601153,CDM,636,RC,J2175,HCPCS,Both,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.21,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,7.5,125.18,,,fee schedule,125.18% of custom fee schedule,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,7.21,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.21,67.5,
NF-DEMEROL (MEPERIDINE HCL) INJ : 75MG,2601154,CDM,636,RC,J2175,HCPCS,Both,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.21,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,7.5,125.18,,,fee schedule,125.18% of custom fee schedule,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,7.21,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.21,67.5,
DEMEROL (MEPERIDINE HCL) INJ 25MG,2601155,CDM,636,RC,J2175,HCPCS,Both,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7.21,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,7.5,125.18,,,fee schedule,125.18% of custom fee schedule,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,7.21,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,7.21,67.5,
FENTANYL CITRATE INJ 100MCG,2601165,CDM,636,RC,J3010,HCPCS,Both,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,1.07,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,1.11,125.18,,,fee schedule,125.18% of custom fee schedule,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,1.07,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1.07,67.5,
METHERGIN (METHYLERGONAVINE) INJ 0.2MG,2601362,CDM,636,RC,J2210,HCPCS,Both,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,24.56,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,25.54,125.18,,,fee schedule,125.18% of custom fee schedule,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,24.56,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,18.75,67.5,
MEDROL DP (METHYLPREDNISOLONE) TAB 4MG,2601395,CDM,637,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
CANDIDA SKIN TEST INJ 0.1ML,2601401,CDM,250,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
ZITHROMAX SUSP 100MG/5ML 15ML,2602291,CDM,637,RC,Q0144,HCPCS,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
XYLOCAINE 0.5% MPF (LIDOCAINE) VIAL 50ML,2602292,CDM,636,RC,,,Both,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
NF-ELA-MAX (LIDOCAINE) 4% CREAM : 5GM,2603015,CDM,250,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
XYLOCAINE 1% (LIDOCAINE) MPF VIAL 30ML,2603016,CDM,636,RC,,,Both,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
LAMISIL (TERBINAFINE) TAB 250MG,2603069,CDM,637,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
TAMIFLU (OSELTAMIVIR PHOS) CAP 75MG,2605025,CDM,637,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
TAMIFLU (OSELTAMIVIR PHOS) CAP 45MG,2605026,CDM,637,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
TAMIFLU (OSELTAMIVIR PHOS) CAP 30MG,2605027,CDM,637,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
NF-TEQUIN (GATIFLOXACIN) TAB : 400MG,2605052,CDM,637,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
FENTANYL CITRATE INJ 250MCG,2605072,CDM,636,RC,J3010,HCPCS,Both,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,1.07,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,1.11,125.18,,,fee schedule,125.18% of custom fee schedule,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,1.07,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1.07,67.5,
NF-TEQUIN (GATIFLOXACIN) TAB : 200MG,2605078,CDM,637,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
.IMMUNOASSAY NOT SPECIFIED,3000163,CDM,300,RC,83520,HCPCS,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,130,,,fee schedule,Pays 130% Medicare OPPS,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.61,102,,,fee schedule,Pays 102% Medicare OPPS,67.5,90,,,percent of total billed charges,90% of total billed charges,20.38,125.18,,,fee schedule,125.18% of custom fee schedule,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,15.54,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,130,,,fee schedule,Pays 130% Medicare OPPS,63.75,85,,,percent of total billed charges,85% of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,15.54,67.5,
.SHIGA TOXIN 1,3000663,CDM,306,RC,87045,HCPCS,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,12.27,130,,,fee schedule,Pays 130% Medicare OPPS,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.62,102,,,fee schedule,Pays 102% Medicare OPPS,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,8.49,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,12.27,130,,,fee schedule,Pays 130% Medicare OPPS,63.75,85,,,percent of total billed charges,85% of total billed charges,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,8.49,67.5,
.SHIGA TOXIN 2,3000664,CDM,306,RC,87427,HCPCS,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,15.57,130,,,fee schedule,Pays 130% Medicare OPPS,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.21,102,,,fee schedule,Pays 102% Medicare OPPS,67.5,90,,,percent of total billed charges,90% of total billed charges,18.88,125.18,,,fee schedule,125.18% of custom fee schedule,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,10.78,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,15.57,130,,,fee schedule,Pays 130% Medicare OPPS,63.75,85,,,percent of total billed charges,85% of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,10.78,67.5,
.CAMPYLOBACTER ANTIGEN,3087899,CDM,306,RC,87449,HCPCS,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,15.57,130,,,fee schedule,Pays 130% Medicare OPPS,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.21,102,,,fee schedule,Pays 102% Medicare OPPS,67.5,90,,,percent of total billed charges,90% of total billed charges,18.88,125.18,,,fee schedule,125.18% of custom fee schedule,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,10.78,90,,,fee schedule,Pays 90% Medicare OPPS,43.5,58,,,percent of total billed charges,58% of total billed charges,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,15.57,130,,,fee schedule,Pays 130% Medicare OPPS,63.75,85,,,percent of total billed charges,85% of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,10.78,67.5,
"DRUG SCREEN, HANDLING",3099001,CDM,300,RC,80377,HCPCS,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
OBSERVATION ADDITIONAL HR,4000002,CDM,762,RC,99219,HCPCS,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
PULSE OXIMETRY,5594760,CDM,460,RC,94760,HCPCS,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
SUCTION ABD,7901120,CDM,270,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
LARGE BONE SET,7901199,CDM,270,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
ANASTAMOSIS SET,7901204,CDM,270,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
RESTRAINT VEST CRISS CROSS M117M,7902004,CDM,270,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
SURGICEL 1/2 X 2 BTL,7905088,CDM,272,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
BIOPSY TRAY BASIC SPEC4380,7905110,CDM,270,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
CATH FOLEY ALL SIZE,7905184,CDM,270,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
**DO NOT USE*,7905881,CDM,272,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
FEED TUBE DOBBHOFF,7905919,CDM,270,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
**DO NOT USE**,7950003,CDM,272,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
CATH THORACIC 24FR TROCAR 561050,7950027,CDM,272,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
OP SITE 6 X 8,7950039,CDM,270,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
NEEDLE CATH CENTESIS,7950157,CDM,270,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
NORMLGEL,7950173,CDM,270,RC,,,Outpatient,,,75,60,,63.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,67.5,90,,,percent of total billed charges,90% of total billed charges,26.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,51.53,68.7,,,percent of total billed charges,68.7% of total billed charges,60,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,43.5,58,,,percent of total billed charges,58% of total billed charges,15.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.28,67.5,
ENDO COMPLIANCE KIT,7950322,CDM,272,RC,,,Outpatient,,,78,62.4,,66.3,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,15.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,44.07,56.5,,,percent of total billed charges,56.5 percent of total billed charges,44.07,56.5,,,percent of total billed charges,56.5 percent of total billed charges,44.07,56.5,,,percent of total billed charges,56.5 percent of total billed charges,44.07,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,70.2,90,,,percent of total billed charges,90% of total billed charges,27.3,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,53.59,68.7,,,percent of total billed charges,68.7% of total billed charges,62.4,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,45.24,58,,,percent of total billed charges,58% of total billed charges,15.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,66.3,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.89,70.2,
TRIAMCINOLONE 0.1% LOTION 60ML,2600010,CDM,637,RC,,,Outpatient,,,80,64,,68,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,16.3,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,72,90,,,percent of total billed charges,90% of total billed charges,28,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,54.96,68.7,,,percent of total billed charges,68.7% of total billed charges,64,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,46.4,58,,,percent of total billed charges,58% of total billed charges,16.3,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,68,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,16.3,72,
MORPHINE (DURAMORPH) 1MG/1ML 10ML AMP,2600022,CDM,636,RC,J2270,HCPCS,Both,,,80,64,,68,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.57,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72,90,,,percent of total billed charges,90% of total billed charges,3.72,125.18,,,fee schedule,125.18% of custom fee schedule,54.96,68.7,,,percent of total billed charges,68.7% of total billed charges,64,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,46.4,58,,,percent of total billed charges,58% of total billed charges,3.57,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,68,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.57,72,
KENALOG ORIBASE (TRIAMCIN) 0.1% PASTE,2600431,CDM,637,RC,,,Outpatient,,,80,64,,68,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,16.3,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,72,90,,,percent of total billed charges,90% of total billed charges,28,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,54.96,68.7,,,percent of total billed charges,68.7% of total billed charges,64,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,46.4,58,,,percent of total billed charges,58% of total billed charges,16.3,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,68,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,16.3,72,
PEDIAZOLE (ERY/SULFISOXAZOLE)SUSP:100ML,2600724,CDM,637,RC,,,Outpatient,,,80,64,,68,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,16.3,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,72,90,,,percent of total billed charges,90% of total billed charges,28,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,54.96,68.7,,,percent of total billed charges,68.7% of total billed charges,64,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,46.4,58,,,percent of total billed charges,58% of total billed charges,16.3,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,68,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,16.3,72,
VANCOCIN (VANCOMYCIN HCL) CAP 125MG,2602328,CDM,637,RC,,,Outpatient,,,80,64,,68,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,16.3,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,72,90,,,percent of total billed charges,90% of total billed charges,28,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,54.96,68.7,,,percent of total billed charges,68.7% of total billed charges,64,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,46.4,58,,,percent of total billed charges,58% of total billed charges,16.3,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,68,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,16.3,72,
SKELAXIN (METAXALONE) TAB 800MG,2605159,CDM,637,RC,,,Outpatient,,,80,64,,68,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,16.3,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,72,90,,,percent of total billed charges,90% of total billed charges,28,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,54.96,68.7,,,percent of total billed charges,68.7% of total billed charges,64,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,46.4,58,,,percent of total billed charges,58% of total billed charges,16.3,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,68,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,16.3,72,
"MOLECULAR DIAG, AMP PNA,1",3000207,CDM,301,RC,81223,HCPCS,Outpatient,,,80,64,,68,85,,,percent of total billed charges,85% of total billed charges,499,100,,,fee schedule,Pays 100% Medicare OPPS,499,100,,,fee schedule,Pays 100% Medicare OPPS,499,100,,,fee schedule,Pays 100% Medicare OPPS,648.7,130,,,fee schedule,Pays 130% Medicare OPPS,1155.55,120.37,,,fee schedule,120.37% of custom fee schedule,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,508.98,102,,,fee schedule,Pays 102% Medicare OPPS,72,90,,,percent of total billed charges,90% of total billed charges,1201.73,125.18,,,fee schedule,125.18% of custom fee schedule,54.96,68.7,,,percent of total billed charges,68.7% of total billed charges,64,80,,,percent of total billed charges,80 percent of total billed charges,499,100,,,fee schedule,Pays 100% Medicare OPPS,449.1,90,,,fee schedule,Pays 90% Medicare OPPS,46.4,58,,,percent of total billed charges,58% of total billed charges,1155.55,120.37,,,fee schedule,120.37% of custom fee schedule,499,100,,,fee schedule,Pays 100% Medicare OPPS,648.7,130,,,fee schedule,Pays 130% Medicare OPPS,68,85,,,percent of total billed charges,85% of total billed charges,499,100,,,fee schedule,Pays 100% Medicare OPPS,45.2,1201.73,
Testing for presence of drug,3000647,CDM,301,RC,80307,HCPCS,Outpatient,,,80,64,,68,85,,,percent of total billed charges,85% of total billed charges,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,80.78,130,,,fee schedule,Pays 130% Medicare OPPS,73.62,120.37,,,fee schedule,120.37% of custom fee schedule,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,63.38,102,,,fee schedule,Pays 102% Medicare OPPS,72,90,,,percent of total billed charges,90% of total billed charges,76.56,125.18,,,fee schedule,125.18% of custom fee schedule,54.96,68.7,,,percent of total billed charges,68.7% of total billed charges,64,80,,,percent of total billed charges,80 percent of total billed charges,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,55.92,90,,,fee schedule,Pays 90% Medicare OPPS,46.4,58,,,percent of total billed charges,58% of total billed charges,73.62,120.37,,,fee schedule,120.37% of custom fee schedule,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,80.78,130,,,fee schedule,Pays 130% Medicare OPPS,68,85,,,percent of total billed charges,85% of total billed charges,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,45.2,80.78,
CATH 16 FR. 6146LL,7905175,CDM,270,RC,,,Outpatient,,,80,64,,68,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,16.3,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,72,90,,,percent of total billed charges,90% of total billed charges,28,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,54.96,68.7,,,percent of total billed charges,68.7% of total billed charges,64,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,46.4,58,,,percent of total billed charges,58% of total billed charges,16.3,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,68,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,16.3,72,
**DO NOT USE**,7905622,CDM,272,RC,,,Outpatient,,,80,64,,68,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,16.3,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,72,90,,,percent of total billed charges,90% of total billed charges,28,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,54.96,68.7,,,percent of total billed charges,68.7% of total billed charges,64,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,46.4,58,,,percent of total billed charges,58% of total billed charges,16.3,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,68,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,16.3,72,
RADICAVA (ENDARAVONE) 30MG/100ML PREMIX,2610140,CDM,636,RC,J1301,HCPCS,Both,,,83.33,66.66,,70.83,85,,,percent of total billed charges,85% of total billed charges,21.42,100,,,fee schedule,Pays 100% Medicare OPPS,21.42,100,,,fee schedule,Pays 100% Medicare OPPS,21.42,100,,,fee schedule,Pays 100% Medicare OPPS,27.8,130,,,fee schedule,Pays 130% Medicare OPPS,25.78,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.84,102,,,fee schedule,Pays 102% Medicare OPPS,75,90,,,percent of total billed charges,90% of total billed charges,26.81,125.18,,,fee schedule,125.18% of custom fee schedule,57.25,68.7,,,percent of total billed charges,68.7% of total billed charges,66.66,80,,,percent of total billed charges,80 percent of total billed charges,21.42,100,,,fee schedule,Pays 100% Medicare OPPS,19.27,90,,,fee schedule,Pays 90% Medicare OPPS,48.33,58,,,percent of total billed charges,58% of total billed charges,25.78,120.37,,,fee schedule,120.37% of custom fee schedule,21.39,100,,,fee schedule,Pays 100% Medicare OPPS,27.8,130,,,fee schedule,Pays 130% Medicare OPPS,70.83,85,,,percent of total billed charges,85% of total billed charges,21.42,100,,,fee schedule,Pays 100% Medicare OPPS,19.27,75,
BRA SURGICAL BREAST SUPPORT 2XL 705,7950323,CDM,270,RC,,,Outpatient,,,84,67.2,,71.4,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,47.46,56.5,,,percent of total billed charges,56.5 percent of total billed charges,47.46,56.5,,,percent of total billed charges,56.5 percent of total billed charges,47.46,56.5,,,percent of total billed charges,56.5 percent of total billed charges,47.46,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,75.6,90,,,percent of total billed charges,90% of total billed charges,29.4,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,57.71,68.7,,,percent of total billed charges,68.7% of total billed charges,67.2,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,48.72,58,,,percent of total billed charges,58% of total billed charges,17.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,71.4,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.11,75.6,
OBSERVATION ADDITIONAL HR,100002,CDM,762,RC,G0378,HCPCS,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
SUTURE 3-0 CHROMIC GUT,1570545,CDM,272,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
IRRIGATION TUBING SET SPYGLASS,1750056,CDM,272,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
ATRACURIUM VIAL 50MG/5ML,2600004,CDM,636,RC,,,Both,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
BETADINE (POVIDINE/IODINE) 5% OPHT,2600038,CDM,637,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
TETRACAINE 0.5% EYE DROPS 15ML,2600071,CDM,250,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
SPOT ENDO MARKER,2601008,CDM,636,RC,Q9968,HCPCS,Both,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,8.08,100,,,fee schedule,Pays 100% Medicare OPPS,8.08,100,,,fee schedule,Pays 100% Medicare OPPS,8.08,100,,,fee schedule,Pays 100% Medicare OPPS,9.73,130,,,fee schedule,Pays 130% Medicare OPPS,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.24,102,,,fee schedule,Pays 102% Medicare OPPS,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,8.08,100,,,fee schedule,Pays 100% Medicare OPPS,7.27,90,,,fee schedule,Pays 90% Medicare OPPS,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,7.49,100,,,fee schedule,Pays 100% Medicare OPPS,9.73,130,,,fee schedule,Pays 130% Medicare OPPS,72.25,85,,,percent of total billed charges,85% of total billed charges,8.08,100,,,fee schedule,Pays 100% Medicare OPPS,7.27,76.5,
UNASYN (AMPICILLIN/SULBACTAM) INJ 3GM,2601053,CDM,636,RC,J0295,HCPCS,Both,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.17,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,3.29,125.18,,,fee schedule,125.18% of custom fee schedule,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,3.17,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.17,76.5,
NF-FENTANYL CITRATE INJ 50MCG,2601162,CDM,636,RC,,,Both,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
VERAPAMIL INJ 2.5MG/ML,2601340,CDM,636,RC,,,Both,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
NARCAN (NALOXONE HCL) INJ 0.4MG,2601364,CDM,636,RC,J2310,HCPCS,Both,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12.01,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,12.49,125.18,,,fee schedule,125.18% of custom fee schedule,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,12.01,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,12.01,76.5,
HUMULIN N KWIKPEN,2601436,CDM,637,RC,J1817,HCPCS,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
XYLOCAINE 2% W/EPI (LIDO/EPI) VIAL 20ML,2603017,CDM,636,RC,J2001,HCPCS,Both,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,0.02,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,0.03,125.18,,,fee schedule,125.18% of custom fee schedule,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,0.02,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.02,76.5,
HUMULIN 70/30 KWIKPEN,2605045,CDM,636,RC,J1817,HCPCS,Both,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
LOVENOX (ENOXAPARIN) INJ 100MG,2605092,CDM,636,RC,J1650,HCPCS,Both,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
PROLIA (DENOSUMAB) INJ 60MG,2605095,CDM,636,RC,J0897,HCPCS,Both,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,22.51,100,,,fee schedule,Pays 100% Medicare OPPS,22.51,100,,,fee schedule,Pays 100% Medicare OPPS,22.51,100,,,fee schedule,Pays 100% Medicare OPPS,31.48,130,,,fee schedule,Pays 130% Medicare OPPS,27.1,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.96,102,,,fee schedule,Pays 102% Medicare OPPS,76.5,90,,,percent of total billed charges,90% of total billed charges,28.18,125.18,,,fee schedule,125.18% of custom fee schedule,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,22.51,100,,,fee schedule,Pays 100% Medicare OPPS,20.25,90,,,fee schedule,Pays 90% Medicare OPPS,49.3,58,,,percent of total billed charges,58% of total billed charges,27.1,120.37,,,fee schedule,120.37% of custom fee schedule,24.22,100,,,fee schedule,Pays 100% Medicare OPPS,31.48,130,,,fee schedule,Pays 130% Medicare OPPS,72.25,85,,,percent of total billed charges,85% of total billed charges,22.51,100,,,fee schedule,Pays 100% Medicare OPPS,20.25,76.5,
METHOTREXATE INJ 25MG/ML 2ML VIAL,2605134,CDM,636,RC,J9260,HCPCS,Both,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.15,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,3.28,125.18,,,fee schedule,125.18% of custom fee schedule,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,3.15,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.15,76.5,
TIMENTIN (TICARCILLIN/CLAV) VIAL 3.1GM,2605137,CDM,636,RC,J3490,HCPCS,Both,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
LET SOLUTION TOPICAL SYRINGE 2ML,2605141,CDM,250,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
HUBER NEEDLE W/EXT 20GAX 3/4INCH,2611001,CDM,270,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
HUBER NEEDLE W/EXT 20GAX 1INCH,2611002,CDM,270,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
IV ANGIOCATH 14 GA X 3.25,2613078,CDM,272,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
IV ANGIOCATH 14 GA X 5.25,2613088,CDM,272,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
CRIDER INTERVENT SCREEN,3000077,CDM,300,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
.RA W/(ARTHRITIS PROFILE),3000248,CDM,302,RC,86430,HCPCS,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,6.14,100,,,fee schedule,Pays 100% Medicare OPPS,6.14,100,,,fee schedule,Pays 100% Medicare OPPS,6.14,100,,,fee schedule,Pays 100% Medicare OPPS,7.98,130,,,fee schedule,Pays 130% Medicare OPPS,8.59,120.37,,,fee schedule,120.37% of custom fee schedule,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.26,102,,,fee schedule,Pays 102% Medicare OPPS,76.5,90,,,percent of total billed charges,90% of total billed charges,8.94,125.18,,,fee schedule,125.18% of custom fee schedule,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,6.14,100,,,fee schedule,Pays 100% Medicare OPPS,5.52,90,,,fee schedule,Pays 90% Medicare OPPS,49.3,58,,,percent of total billed charges,58% of total billed charges,8.59,120.37,,,fee schedule,120.37% of custom fee schedule,6.14,100,,,fee schedule,Pays 100% Medicare OPPS,7.98,130,,,fee schedule,Pays 130% Medicare OPPS,72.25,85,,,percent of total billed charges,85% of total billed charges,6.14,100,,,fee schedule,Pays 100% Medicare OPPS,5.52,76.5,
.TRIPLE TEST (BETA HCG),3000313,CDM,301,RC,84702,HCPCS,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,15.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.05,100,,,fee schedule,Pays 100% Medicare OPPS,19.56,130,,,fee schedule,Pays 130% Medicare OPPS,9.71,120.37,,,fee schedule,120.37% of custom fee schedule,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.35,102,,,fee schedule,Pays 102% Medicare OPPS,76.5,90,,,percent of total billed charges,90% of total billed charges,10.1,125.18,,,fee schedule,125.18% of custom fee schedule,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,15.05,100,,,fee schedule,Pays 100% Medicare OPPS,13.54,90,,,fee schedule,Pays 90% Medicare OPPS,49.3,58,,,percent of total billed charges,58% of total billed charges,9.71,120.37,,,fee schedule,120.37% of custom fee schedule,15.05,100,,,fee schedule,Pays 100% Medicare OPPS,19.56,130,,,fee schedule,Pays 130% Medicare OPPS,72.25,85,,,percent of total billed charges,85% of total billed charges,15.05,100,,,fee schedule,Pays 100% Medicare OPPS,9.71,76.5,
RH,3000379,CDM,300,RC,86901,HCPCS,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,38.83,130,,,fee schedule,Pays 130% Medicare OPPS,17.47,120.37,,,fee schedule,120.37% of custom fee schedule,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.01,102,,,fee schedule,Pays 102% Medicare OPPS,76.5,90,,,percent of total billed charges,90% of total billed charges,18.16,125.18,,,fee schedule,125.18% of custom fee schedule,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,27.36,90,,,fee schedule,Pays 90% Medicare OPPS,49.3,58,,,percent of total billed charges,58% of total billed charges,17.47,120.37,,,fee schedule,120.37% of custom fee schedule,29.87,100,,,fee schedule,Pays 100% Medicare OPPS,38.83,130,,,fee schedule,Pays 130% Medicare OPPS,72.25,85,,,percent of total billed charges,85% of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,17.47,76.5,
MOLECULAR DIAG ISOL OR EXT PNA (HLA NAR),3000561,CDM,301,RC,83891,HCPCS,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
MOLECULAR DIAG SEP BY GEL (HLA NAR),3000562,CDM,301,RC,83894,HCPCS,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
MOLECULAR DIAG NAP (HLA NAR),3000563,CDM,301,RC,83896,HCPCS,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
MOLECULAR DIAG I&R (HLA NAR),3000564,CDM,301,RC,83912,HCPCS,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
RC DAT EACH ANTISERA (RC),3008688,CDM,300,RC,86880,HCPCS,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,65.72,130,,,fee schedule,Pays 130% Medicare OPPS,8.12,120.37,,,fee schedule,120.37% of custom fee schedule,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,51,102,,,fee schedule,Pays 102% Medicare OPPS,76.5,90,,,percent of total billed charges,90% of total billed charges,8.45,125.18,,,fee schedule,125.18% of custom fee schedule,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,45,90,,,fee schedule,Pays 90% Medicare OPPS,49.3,58,,,percent of total billed charges,58% of total billed charges,8.12,120.37,,,fee schedule,120.37% of custom fee schedule,50.55,100,,,fee schedule,Pays 100% Medicare OPPS,65.72,130,,,fee schedule,Pays 130% Medicare OPPS,72.25,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,8.12,76.5,
ANDROSTENEDIONE,3082157,CDM,301,RC,82157,HCPCS,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,29.28,100,,,fee schedule,Pays 100% Medicare OPPS,29.28,100,,,fee schedule,Pays 100% Medicare OPPS,29.28,100,,,fee schedule,Pays 100% Medicare OPPS,38.06,130,,,fee schedule,Pays 130% Medicare OPPS,44.31,120.37,,,fee schedule,120.37% of custom fee schedule,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,29.86,102,,,fee schedule,Pays 102% Medicare OPPS,76.5,90,,,percent of total billed charges,90% of total billed charges,46.08,125.18,,,fee schedule,125.18% of custom fee schedule,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,29.28,100,,,fee schedule,Pays 100% Medicare OPPS,26.35,90,,,fee schedule,Pays 90% Medicare OPPS,49.3,58,,,percent of total billed charges,58% of total billed charges,44.31,120.37,,,fee schedule,120.37% of custom fee schedule,29.28,100,,,fee schedule,Pays 100% Medicare OPPS,38.06,130,,,fee schedule,Pays 130% Medicare OPPS,72.25,85,,,percent of total billed charges,85% of total billed charges,29.28,100,,,fee schedule,Pays 100% Medicare OPPS,26.35,76.5,
CADMIUM URINE,3082300,CDM,301,RC,82300,HCPCS,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,23.64,100,,,fee schedule,Pays 100% Medicare OPPS,23.64,100,,,fee schedule,Pays 100% Medicare OPPS,23.64,100,,,fee schedule,Pays 100% Medicare OPPS,30.73,130,,,fee schedule,Pays 130% Medicare OPPS,35.03,120.37,,,fee schedule,120.37% of custom fee schedule,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,24.11,102,,,fee schedule,Pays 102% Medicare OPPS,76.5,90,,,percent of total billed charges,90% of total billed charges,36.43,125.18,,,fee schedule,125.18% of custom fee schedule,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,23.64,100,,,fee schedule,Pays 100% Medicare OPPS,21.27,90,,,fee schedule,Pays 90% Medicare OPPS,49.3,58,,,percent of total billed charges,58% of total billed charges,35.03,120.37,,,fee schedule,120.37% of custom fee schedule,23.64,100,,,fee schedule,Pays 100% Medicare OPPS,30.73,130,,,fee schedule,Pays 130% Medicare OPPS,72.25,85,,,percent of total billed charges,85% of total billed charges,23.64,100,,,fee schedule,Pays 100% Medicare OPPS,21.27,76.5,
MOLECULAR DIAG AMP OF PNA(HLA NAR),3083900,CDM,301,RC,83900,HCPCS,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
MOLECULAR DIAG SEP & ID (HLA NAR),3083909,CDM,301,RC,83909,HCPCS,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
Blood test to assess for infection,3085007,CDM,305,RC,85007,HCPCS,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,3.8,100,,,fee schedule,Pays 100% Medicare OPPS,3.8,100,,,fee schedule,Pays 100% Medicare OPPS,3.8,100,,,fee schedule,Pays 100% Medicare OPPS,4.94,130,,,fee schedule,Pays 130% Medicare OPPS,5.21,120.37,,,fee schedule,120.37% of custom fee schedule,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3.87,102,,,fee schedule,Pays 102% Medicare OPPS,76.5,90,,,percent of total billed charges,90% of total billed charges,5.42,125.18,,,fee schedule,125.18% of custom fee schedule,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,3.8,100,,,fee schedule,Pays 100% Medicare OPPS,3.42,90,,,fee schedule,Pays 90% Medicare OPPS,49.3,58,,,percent of total billed charges,58% of total billed charges,5.21,120.37,,,fee schedule,120.37% of custom fee schedule,3.8,100,,,fee schedule,Pays 100% Medicare OPPS,4.94,130,,,fee schedule,Pays 130% Medicare OPPS,72.25,85,,,percent of total billed charges,85% of total billed charges,3.8,100,,,fee schedule,Pays 100% Medicare OPPS,3.42,76.5,
CRYPTOCOCCUS AB,3086641,CDM,301,RC,86641,HCPCS,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,14.41,100,,,fee schedule,Pays 100% Medicare OPPS,14.41,100,,,fee schedule,Pays 100% Medicare OPPS,14.41,100,,,fee schedule,Pays 100% Medicare OPPS,18.73,130,,,fee schedule,Pays 130% Medicare OPPS,21.82,120.37,,,fee schedule,120.37% of custom fee schedule,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.69,102,,,fee schedule,Pays 102% Medicare OPPS,76.5,90,,,percent of total billed charges,90% of total billed charges,22.7,125.18,,,fee schedule,125.18% of custom fee schedule,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,14.41,100,,,fee schedule,Pays 100% Medicare OPPS,12.96,90,,,fee schedule,Pays 90% Medicare OPPS,49.3,58,,,percent of total billed charges,58% of total billed charges,21.82,120.37,,,fee schedule,120.37% of custom fee schedule,14.41,100,,,fee schedule,Pays 100% Medicare OPPS,18.73,130,,,fee schedule,Pays 130% Medicare OPPS,72.25,85,,,percent of total billed charges,85% of total billed charges,14.41,100,,,fee schedule,Pays 100% Medicare OPPS,12.96,76.5,
BB RH BLOOD TYPE,3086901,CDM,300,RC,86901,HCPCS,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,38.83,130,,,fee schedule,Pays 130% Medicare OPPS,17.47,120.37,,,fee schedule,120.37% of custom fee schedule,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.01,102,,,fee schedule,Pays 102% Medicare OPPS,76.5,90,,,percent of total billed charges,90% of total billed charges,18.16,125.18,,,fee schedule,125.18% of custom fee schedule,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,27.36,90,,,fee schedule,Pays 90% Medicare OPPS,49.3,58,,,percent of total billed charges,58% of total billed charges,17.47,120.37,,,fee schedule,120.37% of custom fee schedule,29.87,100,,,fee schedule,Pays 100% Medicare OPPS,38.83,130,,,fee schedule,Pays 130% Medicare OPPS,72.25,85,,,percent of total billed charges,85% of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,17.47,76.5,
ENTAMOEBA HISTOLYTICA ANTIGEN,3087337,CDM,306,RC,87337,HCPCS,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,15.57,130,,,fee schedule,Pays 130% Medicare OPPS,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.21,102,,,fee schedule,Pays 102% Medicare OPPS,76.5,90,,,percent of total billed charges,90% of total billed charges,18.88,125.18,,,fee schedule,125.18% of custom fee schedule,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,10.78,90,,,fee schedule,Pays 90% Medicare OPPS,49.3,58,,,percent of total billed charges,58% of total billed charges,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,15.57,130,,,fee schedule,Pays 130% Medicare OPPS,72.25,85,,,percent of total billed charges,85% of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,10.78,76.5,
88104 CYTOPATHOLOGY FL NONGYN SMEARS,3200002,CDM,311,RC,88104,HCPCS,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,38.83,130,,,fee schedule,Pays 130% Medicare OPPS,51.37,120.37,,,fee schedule,120.37% of custom fee schedule,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.01,102,,,fee schedule,Pays 102% Medicare OPPS,76.5,90,,,percent of total billed charges,90% of total billed charges,53.43,125.18,,,fee schedule,125.18% of custom fee schedule,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,27.36,90,,,fee schedule,Pays 90% Medicare OPPS,49.3,58,,,percent of total billed charges,58% of total billed charges,51.37,120.37,,,fee schedule,120.37% of custom fee schedule,29.87,100,,,fee schedule,Pays 100% Medicare OPPS,38.83,130,,,fee schedule,Pays 130% Medicare OPPS,72.25,85,,,percent of total billed charges,85% of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,27.36,76.5,
88108 CP CONCENTRATION TECH SMEAR,3200003,CDM,311,RC,88108,HCPCS,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,38.83,130,,,fee schedule,Pays 130% Medicare OPPS,55.06,120.37,,,fee schedule,120.37% of custom fee schedule,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.01,102,,,fee schedule,Pays 102% Medicare OPPS,76.5,90,,,percent of total billed charges,90% of total billed charges,57.26,125.18,,,fee schedule,125.18% of custom fee schedule,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,27.36,90,,,fee schedule,Pays 90% Medicare OPPS,49.3,58,,,percent of total billed charges,58% of total billed charges,55.06,120.37,,,fee schedule,120.37% of custom fee schedule,29.87,100,,,fee schedule,Pays 100% Medicare OPPS,38.83,130,,,fee schedule,Pays 130% Medicare OPPS,72.25,85,,,percent of total billed charges,85% of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,27.36,76.5,
Blood test to assist with diagnosis,3200012,CDM,310,RC,88312,HCPCS,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,57.33,130,,,fee schedule,Pays 130% Medicare OPPS,52.23,120.37,,,fee schedule,120.37% of custom fee schedule,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.53,102,,,fee schedule,Pays 102% Medicare OPPS,76.5,90,,,percent of total billed charges,90% of total billed charges,54.32,125.18,,,fee schedule,125.18% of custom fee schedule,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,40.17,90,,,fee schedule,Pays 90% Medicare OPPS,49.3,58,,,percent of total billed charges,58% of total billed charges,52.23,120.37,,,fee schedule,120.37% of custom fee schedule,44.1,100,,,fee schedule,Pays 100% Medicare OPPS,57.33,130,,,fee schedule,Pays 130% Medicare OPPS,72.25,85,,,percent of total billed charges,85% of total billed charges,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,40.17,76.5,
Blood test to assist with diagnosis,3200013,CDM,310,RC,88313,HCPCS,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,38.83,130,,,fee schedule,Pays 130% Medicare OPPS,54.06,120.37,,,fee schedule,120.37% of custom fee schedule,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.01,102,,,fee schedule,Pays 102% Medicare OPPS,76.5,90,,,percent of total billed charges,90% of total billed charges,56.22,125.18,,,fee schedule,125.18% of custom fee schedule,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,27.36,90,,,fee schedule,Pays 90% Medicare OPPS,49.3,58,,,percent of total billed charges,58% of total billed charges,54.06,120.37,,,fee schedule,120.37% of custom fee schedule,29.87,100,,,fee schedule,Pays 100% Medicare OPPS,38.83,130,,,fee schedule,Pays 130% Medicare OPPS,72.25,85,,,percent of total billed charges,85% of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,27.36,76.5,
COPY FILM PER X-RAY EXAM,4000803,CDM,270,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
SPLINT LONG ARM W/RDIAL BAR TAILOR,5007543,CDM,270,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
NASO TRACHEAL SUCTION,5531720,CDM,410,RC,31720,HCPCS,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,172.23,102,,,fee schedule,Pays 102% Medicare OPPS,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,151.96,90,,,fee schedule,Pays 90% Medicare OPPS,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,168.43,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,72.25,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,17.31,218.97,
BLADE OSCILLATING SAW KM-3001,7901051,CDM,270,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
BLADE SAGITTAL SAW KM-3107,7901052,CDM,270,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
BASIC OTHO TRAY,7901197,CDM,270,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
KNEE SET,7901206,CDM,270,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
CIRCUMCISION SET,7901208,CDM,270,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
HEANEY UTERINE CLAMP,7901213,CDM,270,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
FORCEP BIOPSY DISP. FB240U.A,7905046,CDM,272,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
FORCEP BIOPSY RADIAL JAW 4,7905050,CDM,272,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
SILASTIC DRAIN 7/16,7905075,CDM,270,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
SNARE DISPOSABLE SD210U25,7905162,CDM,272,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
SNARE DISPOSABLE 6240-40,7905164,CDM,270,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
SNARE DISPOSABLE CAPTIVATOR II 6119,7905225,CDM,272,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
SNARE DISPOSABLE CAPTIVATOR II 6129 XL,7905228,CDM,272,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
SNARE DISPOSABLE 6267-40,7905271,CDM,270,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
LUMBAR PUN TRAY PED 4302CSP,7905415,CDM,270,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
CWV RESERVOIR,7905741,CDM,270,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
DRESSING SORBSAN,7905836,CDM,270,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
...NEBULIZER SET,7919302,CDM,270,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
ELECTRODE SPIRAL 7000AAO,7950013,CDM,270,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
SUTURE 5-0 VICRYL J391H,7950038,CDM,272,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
CATH THORACIC 32FR TROCAR 561076,7950041,CDM,272,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
CATH THORACIC 28FR TROCAR 561068,7950045,CDM,272,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
SUTURE 3-0 CHROMIC G122H,7950096,CDM,272,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
MYELOGRAM TRAY,7950235,CDM,270,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
MYELOGRAM TRAY 956,7950236,CDM,270,RC,,,Outpatient,,,85,68,,72.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,76.5,90,,,percent of total billed charges,90% of total billed charges,29.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,58.4,68.7,,,percent of total billed charges,68.7% of total billed charges,68,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.3,58,,,percent of total billed charges,58% of total billed charges,17.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,72.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.31,76.5,
CANNULA ADULT NASAL HIGH FLOW SMALL,7950314,CDM,270,RC,,,Outpatient,,,86,68.8,,73.1,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.59,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.59,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.59,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.59,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,77.4,90,,,percent of total billed charges,90% of total billed charges,30.1,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,59.08,68.7,,,percent of total billed charges,68.7% of total billed charges,68.8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.88,58,,,percent of total billed charges,58% of total billed charges,17.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,73.1,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.52,77.4,
CANNULA ADULT NASAL HIGH FLOW MED,7950315,CDM,270,RC,,,Outpatient,,,86,68.8,,73.1,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,48.59,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.59,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.59,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.59,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,77.4,90,,,percent of total billed charges,90% of total billed charges,30.1,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,59.08,68.7,,,percent of total billed charges,68.7% of total billed charges,68.8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,49.88,58,,,percent of total billed charges,58% of total billed charges,17.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,73.1,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.52,77.4,
OBTURATOR KII OPTICAL CTR03,1570084,CDM,270,RC,,,Outpatient,,,90,72,,76.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,81,90,,,percent of total billed charges,90% of total billed charges,31.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,61.83,68.7,,,percent of total billed charges,68.7% of total billed charges,72,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,52.2,58,,,percent of total billed charges,58% of total billed charges,18.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,18.33,81,
OBTURATOR KII OPTICAL CTR01,1570790,CDM,270,RC,,,Outpatient,,,90,72,,76.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,81,90,,,percent of total billed charges,90% of total billed charges,31.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,61.83,68.7,,,percent of total billed charges,68.7% of total billed charges,72,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,52.2,58,,,percent of total billed charges,58% of total billed charges,18.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,18.33,81,
RAPID REFILL CONTINUOUS INJ SYSTEM,1750024,CDM,272,RC,,,Outpatient,,,90,72,,76.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,81,90,,,percent of total billed charges,90% of total billed charges,31.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,61.83,68.7,,,percent of total billed charges,68.7% of total billed charges,72,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,52.2,58,,,percent of total billed charges,58% of total billed charges,18.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,18.33,81,
CORTISPOR (NEOMYCIN/POLY/CORT) EYE OINT,2600104,CDM,637,RC,,,Outpatient,,,90,72,,76.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,81,90,,,percent of total billed charges,90% of total billed charges,31.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,61.83,68.7,,,percent of total billed charges,68.7% of total billed charges,72,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,52.2,58,,,percent of total billed charges,58% of total billed charges,18.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,18.33,81,
GRANULEX (TBC SPRAY BOTTLE),2600423,CDM,637,RC,,,Outpatient,,,90,72,,76.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,81,90,,,percent of total billed charges,90% of total billed charges,31.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,61.83,68.7,,,percent of total billed charges,68.7% of total billed charges,72,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,52.2,58,,,percent of total billed charges,58% of total billed charges,18.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,18.33,81,
DIPRIVAN (PROPOFOL 1%) VIAL 50ML,2601158,CDM,636,RC,,,Both,,,90,72,,76.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,81,90,,,percent of total billed charges,90% of total billed charges,31.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,61.83,68.7,,,percent of total billed charges,68.7% of total billed charges,72,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,52.2,58,,,percent of total billed charges,58% of total billed charges,18.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,18.33,81,
GEODON (ZIPRASIDONE) INJ 20MG/ML,2601318,CDM,636,RC,J3486,HCPCS,Both,,,90,72,,76.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,13.22,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,81,90,,,percent of total billed charges,90% of total billed charges,13.74,125.18,,,fee schedule,125.18% of custom fee schedule,61.83,68.7,,,percent of total billed charges,68.7% of total billed charges,72,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,52.2,58,,,percent of total billed charges,58% of total billed charges,13.22,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.22,81,
NIZORAL (KETOCONAZOLE) 2% CRM,2602205,CDM,637,RC,,,Outpatient,,,90,72,,76.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,81,90,,,percent of total billed charges,90% of total billed charges,31.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,61.83,68.7,,,percent of total billed charges,68.7% of total billed charges,72,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,52.2,58,,,percent of total billed charges,58% of total billed charges,18.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,18.33,81,
Blood test to screen for antibodies that could harm red blood cells,3008685,CDM,300,RC,86850,HCPCS,Outpatient,,,90,72,,76.5,85,,,percent of total billed charges,85% of total billed charges,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,57.33,130,,,fee schedule,Pays 130% Medicare OPPS,18.33,120.37,,,fee schedule,120.37% of custom fee schedule,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.53,102,,,fee schedule,Pays 102% Medicare OPPS,81,90,,,percent of total billed charges,90% of total billed charges,19.06,125.18,,,fee schedule,125.18% of custom fee schedule,61.83,68.7,,,percent of total billed charges,68.7% of total billed charges,72,80,,,percent of total billed charges,80 percent of total billed charges,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,40.17,90,,,fee schedule,Pays 90% Medicare OPPS,52.2,58,,,percent of total billed charges,58% of total billed charges,18.33,120.37,,,fee schedule,120.37% of custom fee schedule,44.1,100,,,fee schedule,Pays 100% Medicare OPPS,57.33,130,,,fee schedule,Pays 130% Medicare OPPS,76.5,85,,,percent of total billed charges,85% of total billed charges,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,18.33,81,
**DO NOT USE***,7905637,CDM,272,RC,,,Outpatient,,,90,72,,76.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,81,90,,,percent of total billed charges,90% of total billed charges,31.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,61.83,68.7,,,percent of total billed charges,68.7% of total billed charges,72,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,52.2,58,,,percent of total billed charges,58% of total billed charges,18.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,18.33,81,
***DO NOT USE***,7905907,CDM,272,RC,,,Outpatient,,,90,72,,76.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,50.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,81,90,,,percent of total billed charges,90% of total billed charges,31.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,61.83,68.7,,,percent of total billed charges,68.7% of total billed charges,72,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,52.2,58,,,percent of total billed charges,58% of total billed charges,18.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,18.33,81,
BRA SURGICAL BREAST SUPPORT LARGE DL703,7950317,CDM,270,RC,,,Outpatient,,,94,75.2,,79.9,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,19.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.11,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.11,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.11,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.11,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,84.6,90,,,percent of total billed charges,90% of total billed charges,32.9,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,64.58,68.7,,,percent of total billed charges,68.7% of total billed charges,75.2,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,54.52,58,,,percent of total billed charges,58% of total billed charges,19.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,79.9,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.15,84.6,
BRA SURGICAL BREAST SUPPORT XL DL704,7950320,CDM,270,RC,,,Outpatient,,,94,75.2,,79.9,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,19.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.11,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.11,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.11,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.11,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,84.6,90,,,percent of total billed charges,90% of total billed charges,32.9,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,64.58,68.7,,,percent of total billed charges,68.7% of total billed charges,75.2,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,54.52,58,,,percent of total billed charges,58% of total billed charges,19.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,79.9,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.15,84.6,
SUTURE 3-0 PROLENE 38622,1570551,CDM,272,RC,,,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
TUBING SET UNIDRIVE ENT/OMFS,1570761,CDM,272,RC,,,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
RETRACTOR HANDHELD SOFT TISSUE DISPO,1570800,CDM,272,RC,,,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
TOBRAMYCIN 0.3% OPHTHALMIC DROPS,2600041,CDM,637,RC,,,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
FERRLECIT (IRON GLUCONATE) INJ 12.5MG/ML,2600185,CDM,250,RC,,,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
TIMOPTIC XE (TIMOLOL GFS) 0.5% OPHT DROP,2600332,CDM,637,RC,,,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
BLEPHAMIDE (SULFACET/PRED) OPHTH DROP,2600343,CDM,637,RC,,,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
NYSTATIN ORAL LIQ 60ML,2600722,CDM,637,RC,,,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
ANECTINE (SUCCINYLCHOLINE) INJ : 200MG,2601257,CDM,636,RC,J0330,HCPCS,Both,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
"BACITRACIN INJ : 50,000 UNITS",2601314,CDM,636,RC,,,Both,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
XYLOCAINE 2% W/EPI (LIDO/EPI) MPF 10ML,2601351,CDM,250,RC,,,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
PPD TEST (TUBERCULIN SKIN TEST) INJ,2601383,CDM,250,RC,86580,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,22.19,100,,,fee schedule,Pays 100% Medicare OPPS,22.19,100,,,fee schedule,Pays 100% Medicare OPPS,22.19,100,,,fee schedule,Pays 100% Medicare OPPS,28.54,130,,,fee schedule,Pays 130% Medicare OPPS,9.79,120.37,,,fee schedule,120.37% of custom fee schedule,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.63,102,,,fee schedule,Pays 102% Medicare OPPS,85.5,90,,,percent of total billed charges,90% of total billed charges,10.18,125.18,,,fee schedule,125.18% of custom fee schedule,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,22.19,100,,,fee schedule,Pays 100% Medicare OPPS,19.97,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,9.79,120.37,,,fee schedule,120.37% of custom fee schedule,21.95,100,,,fee schedule,Pays 100% Medicare OPPS,28.54,130,,,fee schedule,Pays 130% Medicare OPPS,80.75,85,,,percent of total billed charges,85% of total billed charges,22.19,100,,,fee schedule,Pays 100% Medicare OPPS,9.79,85.5,
ATIVAN (LORAZEPAM) INJ 2MG,2602100,CDM,636,RC,J2060,HCPCS,Both,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
VITAMIN B-1 (THIAMINE HCL) INJ 100MG,2602845,CDM,636,RC,J3411,HCPCS,Both,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
ZOTO-HC OTIC DROPS,2605044,CDM,637,RC,,,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,23.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
HUMALOG KWIKPEN,2605049,CDM,637,RC,S5551,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
HUMALOG 75/25 KWIKPEN,2605122,CDM,637,RC,J1817,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
PROCALAMINE AA3% GLYERIN3% w LYTES 1L,2611014,CDM,250,RC,,,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
Test to determine levels of immunoglobulins in the blood,3000175,CDM,301,RC,82784,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,12.09,130,,,fee schedule,Pays 130% Medicare OPPS,14.07,120.37,,,fee schedule,120.37% of custom fee schedule,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.48,102,,,fee schedule,Pays 102% Medicare OPPS,85.5,90,,,percent of total billed charges,90% of total billed charges,14.63,125.18,,,fee schedule,125.18% of custom fee schedule,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,8.37,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,14.07,120.37,,,fee schedule,120.37% of custom fee schedule,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,12.09,130,,,fee schedule,Pays 130% Medicare OPPS,80.75,85,,,percent of total billed charges,85% of total billed charges,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,8.37,85.5,
PHOSOPOLIPIDS AB,3000649,CDM,301,RC,84311,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,8.1,100,,,fee schedule,Pays 100% Medicare OPPS,8.1,100,,,fee schedule,Pays 100% Medicare OPPS,8.1,100,,,fee schedule,Pays 100% Medicare OPPS,10.53,130,,,fee schedule,Pays 130% Medicare OPPS,10.58,120.37,,,fee schedule,120.37% of custom fee schedule,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.26,102,,,fee schedule,Pays 102% Medicare OPPS,85.5,90,,,percent of total billed charges,90% of total billed charges,11,125.18,,,fee schedule,125.18% of custom fee schedule,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,8.1,100,,,fee schedule,Pays 100% Medicare OPPS,7.29,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,10.58,120.37,,,fee schedule,120.37% of custom fee schedule,8.1,100,,,fee schedule,Pays 100% Medicare OPPS,10.53,130,,,fee schedule,Pays 130% Medicare OPPS,80.75,85,,,percent of total billed charges,85% of total billed charges,8.1,100,,,fee schedule,Pays 100% Medicare OPPS,7.29,85.5,
WBC BF,3000720,CDM,305,RC,89050,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,6.13,130,,,fee schedule,Pays 130% Medicare OPPS,7.16,120.37,,,fee schedule,120.37% of custom fee schedule,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.81,102,,,fee schedule,Pays 102% Medicare OPPS,85.5,90,,,percent of total billed charges,90% of total billed charges,7.45,125.18,,,fee schedule,125.18% of custom fee schedule,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.24,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,7.16,120.37,,,fee schedule,120.37% of custom fee schedule,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,6.13,130,,,fee schedule,Pays 130% Medicare OPPS,80.75,85,,,percent of total billed charges,85% of total billed charges,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.24,85.5,
RBC BF,3000721,CDM,305,RC,89050,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,6.13,130,,,fee schedule,Pays 130% Medicare OPPS,7.16,120.37,,,fee schedule,120.37% of custom fee schedule,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.81,102,,,fee schedule,Pays 102% Medicare OPPS,85.5,90,,,percent of total billed charges,90% of total billed charges,7.45,125.18,,,fee schedule,125.18% of custom fee schedule,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.24,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,7.16,120.37,,,fee schedule,120.37% of custom fee schedule,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,6.13,130,,,fee schedule,Pays 130% Medicare OPPS,80.75,85,,,percent of total billed charges,85% of total billed charges,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.24,85.5,
Automated urinalysis test,3081003,CDM,307,RC,81003,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,2.25,100,,,fee schedule,Pays 100% Medicare OPPS,2.25,100,,,fee schedule,Pays 100% Medicare OPPS,2.25,100,,,fee schedule,Pays 100% Medicare OPPS,2.92,130,,,fee schedule,Pays 130% Medicare OPPS,3.41,120.37,,,fee schedule,120.37% of custom fee schedule,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2.29,102,,,fee schedule,Pays 102% Medicare OPPS,85.5,90,,,percent of total billed charges,90% of total billed charges,3.54,125.18,,,fee schedule,125.18% of custom fee schedule,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,2.25,100,,,fee schedule,Pays 100% Medicare OPPS,2.02,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,3.41,120.37,,,fee schedule,120.37% of custom fee schedule,2.25,100,,,fee schedule,Pays 100% Medicare OPPS,2.92,130,,,fee schedule,Pays 130% Medicare OPPS,80.75,85,,,percent of total billed charges,85% of total billed charges,2.25,100,,,fee schedule,Pays 100% Medicare OPPS,2.02,85.5,
URINALYSIS MICROSCO,3081015,CDM,307,RC,81015,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,3.05,100,,,fee schedule,Pays 100% Medicare OPPS,3.05,100,,,fee schedule,Pays 100% Medicare OPPS,3.05,100,,,fee schedule,Pays 100% Medicare OPPS,3.96,130,,,fee schedule,Pays 130% Medicare OPPS,4.6,120.37,,,fee schedule,120.37% of custom fee schedule,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3.11,102,,,fee schedule,Pays 102% Medicare OPPS,85.5,90,,,percent of total billed charges,90% of total billed charges,4.78,125.18,,,fee schedule,125.18% of custom fee schedule,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,3.05,100,,,fee schedule,Pays 100% Medicare OPPS,2.74,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,4.6,120.37,,,fee schedule,120.37% of custom fee schedule,3.05,100,,,fee schedule,Pays 100% Medicare OPPS,3.96,130,,,fee schedule,Pays 130% Medicare OPPS,80.75,85,,,percent of total billed charges,85% of total billed charges,3.05,100,,,fee schedule,Pays 100% Medicare OPPS,2.74,85.5,
HEMOCULT 1-3 SPCMN,3082273,CDM,300,RC,82270,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,4.38,100,,,fee schedule,Pays 100% Medicare OPPS,4.38,100,,,fee schedule,Pays 100% Medicare OPPS,4.38,100,,,fee schedule,Pays 100% Medicare OPPS,5.69,130,,,fee schedule,Pays 130% Medicare OPPS,4.86,120.37,,,fee schedule,120.37% of custom fee schedule,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.46,102,,,fee schedule,Pays 102% Medicare OPPS,85.5,90,,,percent of total billed charges,90% of total billed charges,5.06,125.18,,,fee schedule,125.18% of custom fee schedule,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,4.38,100,,,fee schedule,Pays 100% Medicare OPPS,3.94,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,4.86,120.37,,,fee schedule,120.37% of custom fee schedule,4.38,100,,,fee schedule,Pays 100% Medicare OPPS,5.69,130,,,fee schedule,Pays 130% Medicare OPPS,80.75,85,,,percent of total billed charges,85% of total billed charges,4.38,100,,,fee schedule,Pays 100% Medicare OPPS,3.94,85.5,
IGF BINDING PROTEIN-3,3082397,CDM,305,RC,82397,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,14.12,100,,,fee schedule,Pays 100% Medicare OPPS,14.12,100,,,fee schedule,Pays 100% Medicare OPPS,14.12,100,,,fee schedule,Pays 100% Medicare OPPS,18.35,130,,,fee schedule,Pays 130% Medicare OPPS,21.39,120.37,,,fee schedule,120.37% of custom fee schedule,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.4,102,,,fee schedule,Pays 102% Medicare OPPS,85.5,90,,,percent of total billed charges,90% of total billed charges,22.24,125.18,,,fee schedule,125.18% of custom fee schedule,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,14.12,100,,,fee schedule,Pays 100% Medicare OPPS,12.7,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,21.39,120.37,,,fee schedule,120.37% of custom fee schedule,14.12,100,,,fee schedule,Pays 100% Medicare OPPS,18.35,130,,,fee schedule,Pays 130% Medicare OPPS,80.75,85,,,percent of total billed charges,85% of total billed charges,14.12,100,,,fee schedule,Pays 100% Medicare OPPS,12.7,85.5,
Test to determine levels of immunoglobulins in the blood,3082784,CDM,301,RC,82784,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,12.09,130,,,fee schedule,Pays 130% Medicare OPPS,14.07,120.37,,,fee schedule,120.37% of custom fee schedule,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.48,102,,,fee schedule,Pays 102% Medicare OPPS,85.5,90,,,percent of total billed charges,90% of total billed charges,14.63,125.18,,,fee schedule,125.18% of custom fee schedule,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,8.37,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,14.07,120.37,,,fee schedule,120.37% of custom fee schedule,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,12.09,130,,,fee schedule,Pays 130% Medicare OPPS,80.75,85,,,percent of total billed charges,85% of total billed charges,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,8.37,85.5,
HEMATOCRIT,3085014,CDM,305,RC,85014,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,2.37,100,,,fee schedule,Pays 100% Medicare OPPS,2.37,100,,,fee schedule,Pays 100% Medicare OPPS,2.37,100,,,fee schedule,Pays 100% Medicare OPPS,3.08,130,,,fee schedule,Pays 130% Medicare OPPS,3.59,120.37,,,fee schedule,120.37% of custom fee schedule,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2.41,102,,,fee schedule,Pays 102% Medicare OPPS,85.5,90,,,percent of total billed charges,90% of total billed charges,3.73,125.18,,,fee schedule,125.18% of custom fee schedule,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,2.37,100,,,fee schedule,Pays 100% Medicare OPPS,2.13,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,3.59,120.37,,,fee schedule,120.37% of custom fee schedule,2.37,100,,,fee schedule,Pays 100% Medicare OPPS,3.08,130,,,fee schedule,Pays 130% Medicare OPPS,80.75,85,,,percent of total billed charges,85% of total billed charges,2.37,100,,,fee schedule,Pays 100% Medicare OPPS,2.13,85.5,
Blood test to measure levels of hemoglobin,3085018,CDM,305,RC,85018,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,2.37,100,,,fee schedule,Pays 100% Medicare OPPS,2.37,100,,,fee schedule,Pays 100% Medicare OPPS,2.37,100,,,fee schedule,Pays 100% Medicare OPPS,3.08,130,,,fee schedule,Pays 130% Medicare OPPS,3.59,120.37,,,fee schedule,120.37% of custom fee schedule,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2.41,102,,,fee schedule,Pays 102% Medicare OPPS,85.5,90,,,percent of total billed charges,90% of total billed charges,3.73,125.18,,,fee schedule,125.18% of custom fee schedule,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,2.37,100,,,fee schedule,Pays 100% Medicare OPPS,2.13,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,3.59,120.37,,,fee schedule,120.37% of custom fee schedule,2.37,100,,,fee schedule,Pays 100% Medicare OPPS,3.08,130,,,fee schedule,Pays 130% Medicare OPPS,80.75,85,,,percent of total billed charges,85% of total billed charges,2.37,100,,,fee schedule,Pays 100% Medicare OPPS,2.13,85.5,
RBC(AUTOMATED),3085041,CDM,305,RC,85041,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,3.02,100,,,fee schedule,Pays 100% Medicare OPPS,3.02,100,,,fee schedule,Pays 100% Medicare OPPS,3.02,100,,,fee schedule,Pays 100% Medicare OPPS,3.92,130,,,fee schedule,Pays 130% Medicare OPPS,4.55,120.37,,,fee schedule,120.37% of custom fee schedule,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3.08,102,,,fee schedule,Pays 102% Medicare OPPS,85.5,90,,,percent of total billed charges,90% of total billed charges,4.73,125.18,,,fee schedule,125.18% of custom fee schedule,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,3.02,100,,,fee schedule,Pays 100% Medicare OPPS,2.71,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,4.55,120.37,,,fee schedule,120.37% of custom fee schedule,3.02,100,,,fee schedule,Pays 100% Medicare OPPS,3.92,130,,,fee schedule,Pays 130% Medicare OPPS,80.75,85,,,percent of total billed charges,85% of total billed charges,3.02,100,,,fee schedule,Pays 100% Medicare OPPS,2.71,85.5,
WBC (AUTOMATED),3085048,CDM,305,RC,85048,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,2.54,100,,,fee schedule,Pays 100% Medicare OPPS,2.54,100,,,fee schedule,Pays 100% Medicare OPPS,2.54,100,,,fee schedule,Pays 100% Medicare OPPS,3.3,130,,,fee schedule,Pays 130% Medicare OPPS,3.85,120.37,,,fee schedule,120.37% of custom fee schedule,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2.59,102,,,fee schedule,Pays 102% Medicare OPPS,85.5,90,,,percent of total billed charges,90% of total billed charges,4.01,125.18,,,fee schedule,125.18% of custom fee schedule,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,2.54,100,,,fee schedule,Pays 100% Medicare OPPS,2.28,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,3.85,120.37,,,fee schedule,120.37% of custom fee schedule,2.54,100,,,fee schedule,Pays 100% Medicare OPPS,3.3,130,,,fee schedule,Pays 130% Medicare OPPS,80.75,85,,,percent of total billed charges,85% of total billed charges,2.54,100,,,fee schedule,Pays 100% Medicare OPPS,2.28,85.5,
RAPID STREP Gp A TEST,3087430,CDM,306,RC,87430,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,16.8,100,,,fee schedule,Pays 100% Medicare OPPS,16.8,100,,,fee schedule,Pays 100% Medicare OPPS,16.8,100,,,fee schedule,Pays 100% Medicare OPPS,21.85,130,,,fee schedule,Pays 130% Medicare OPPS,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.14,102,,,fee schedule,Pays 102% Medicare OPPS,85.5,90,,,percent of total billed charges,90% of total billed charges,18.88,125.18,,,fee schedule,125.18% of custom fee schedule,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,16.8,100,,,fee schedule,Pays 100% Medicare OPPS,15.12,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,16.8,100,,,fee schedule,Pays 100% Medicare OPPS,21.85,130,,,fee schedule,Pays 130% Medicare OPPS,80.75,85,,,percent of total billed charges,85% of total billed charges,16.8,100,,,fee schedule,Pays 100% Medicare OPPS,15.12,85.5,
MOLECULAR DGN SEP & ID,3093909,CDM,301,RC,83909,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
One time use unattended,5197014,CDM,430,RC,97014,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
......INITIAL NEB TX XOPENEX,5500008,CDM,410,RC,94640,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,172.23,102,,,fee schedule,Pays 102% Medicare OPPS,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,151.96,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,168.43,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,80.75,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,19.35,218.97,
......INIT NEB TX ALB/ATRO,5500009,CDM,410,RC,94640,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,172.23,102,,,fee schedule,Pays 102% Medicare OPPS,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,151.96,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,168.43,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,80.75,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,19.35,218.97,
......INITIAL NEB TX ALBUTEROL,5500010,CDM,410,RC,94640,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,172.23,102,,,fee schedule,Pays 102% Medicare OPPS,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,151.96,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,168.43,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,80.75,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,19.35,218.97,
......SUB NEB TX ALBUTEROL,5500011,CDM,410,RC,94640,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,172.23,102,,,fee schedule,Pays 102% Medicare OPPS,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,151.96,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,168.43,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,80.75,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,19.35,218.97,
......SUB NEB TX XOPENEX,5500012,CDM,410,RC,94640,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,172.23,102,,,fee schedule,Pays 102% Medicare OPPS,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,151.96,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,168.43,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,80.75,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,19.35,218.97,
......SUB NEB TX ALB/ATRO,5500013,CDM,410,RC,94640,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,172.23,102,,,fee schedule,Pays 102% Medicare OPPS,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,151.96,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,168.43,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,80.75,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,19.35,218.97,
SPUTUM INDUCTION,5500015,CDM,410,RC,94640,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,172.23,102,,,fee schedule,Pays 102% Medicare OPPS,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,151.96,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,168.43,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,80.75,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,19.35,218.97,
CONTINUOUS INHALATION EACH ADD HR,5594645,CDM,410,RC,94645,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
EVALUATE PT USE OF INHALER,5594665,CDM,410,RC,94664,HCPCS,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,172.23,102,,,fee schedule,Pays 102% Medicare OPPS,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,151.96,90,,,fee schedule,Pays 90% Medicare OPPS,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,168.43,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,80.75,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,19.35,218.97,
BIOPSY TRAY 4382SA,7905109,CDM,270,RC,,,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
**DO NOT USE**,7905115,CDM,272,RC,,,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
CATH MALECOT 34 FR. 361234,7905177,CDM,270,RC,,,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
CATH FOLEY SILASTIC,7905185,CDM,270,RC,,,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
CATH MALECOT 20 FR. 361220,7905190,CDM,270,RC,,,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
KNEE BRACE XXL,7905268,CDM,270,RC,,,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
DRESSING MEPILEX 8 X 8,7905435,CDM,270,RC,,,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
CATH BARTH GLAND,7905569,CDM,270,RC,,,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
THERAPUTTY 2 OZ.,7905664,CDM,270,RC,,,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
CWV DRAIN 10 MM,7905740,CDM,270,RC,,,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
CYTOLOGY BRUSH,7905912,CDM,270,RC,,,Outpatient,,,95,76,,80.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,53.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,85.5,90,,,percent of total billed charges,90% of total billed charges,33.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.27,68.7,,,percent of total billed charges,68.7% of total billed charges,76,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,55.1,58,,,percent of total billed charges,58% of total billed charges,19.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.35,85.5,
NEEDLE BIOPSY TRU-CUT 14 GA. X 6,7950253,CDM,270,RC,,,Outpatient,,,96,76.8,,81.6,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,19.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,54.24,56.5,,,percent of total billed charges,56.5 percent of total billed charges,54.24,56.5,,,percent of total billed charges,56.5 percent of total billed charges,54.24,56.5,,,percent of total billed charges,56.5 percent of total billed charges,54.24,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,86.4,90,,,percent of total billed charges,90% of total billed charges,33.6,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,65.95,68.7,,,percent of total billed charges,68.7% of total billed charges,76.8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,55.68,58,,,percent of total billed charges,58% of total billed charges,19.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,81.6,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,19.56,86.4,
INSERTION UMBILICAL ARTERY,405111,CDM,720,RC,36660,HCPCS,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,100,100,,,fee schedule,Pays 100% Medicare OPPS,100,100,,,fee schedule,Pays 100% Medicare OPPS,100,100,,,fee schedule,Pays 100% Medicare OPPS,100,130,,,fee schedule,Pays 130% Medicare OPPS,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,100,102,,,fee schedule,Pays 102% Medicare OPPS,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,100,100,,,fee schedule,Pays 100% Medicare OPPS,100,90,,,fee schedule,Pays 90% Medicare OPPS,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,100,100,,,fee schedule,Pays 100% Medicare OPPS,100,130,,,fee schedule,Pays 130% Medicare OPPS,85,85,,,percent of total billed charges,85% of total billed charges,100,100,,,fee schedule,Pays 100% Medicare OPPS,20.37,100,
NEOSPORIN (NEO/GRAM/POLY-B) EYE DROP,2600325,CDM,637,RC,,,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,20.37,90,
KEFLEX (CEPHALEXIN) LIQ 250MG/5ML,2600719,CDM,637,RC,,,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,20.37,90,
AQUAMEPHYTON (PHYTONADIONE) INJ 10MG,2601262,CDM,636,RC,J3430,HCPCS,Both,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.98,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,90,90,,,percent of total billed charges,90% of total billed charges,4.14,125.18,,,fee schedule,125.18% of custom fee schedule,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,58,58,,,percent of total billed charges,58% of total billed charges,3.98,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.98,90,
BIAXIN (CLARITHROMYCIN)125MG/5ML SP:50ML,2602321,CDM,637,RC,,,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,20.37,90,
LOVENOX (ENOXAPARIN) INJ 120MG,2605178,CDM,636,RC,J1650,HCPCS,Both,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,20.37,90,
.ASO W/(ARTHRITIS PROFILE),3000025,CDM,302,RC,86063,HCPCS,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,5.77,100,,,fee schedule,Pays 100% Medicare OPPS,5.77,100,,,fee schedule,Pays 100% Medicare OPPS,5.77,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,130,,,fee schedule,Pays 130% Medicare OPPS,8.74,120.37,,,fee schedule,120.37% of custom fee schedule,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.88,102,,,fee schedule,Pays 102% Medicare OPPS,90,90,,,percent of total billed charges,90% of total billed charges,9.09,125.18,,,fee schedule,125.18% of custom fee schedule,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,5.77,100,,,fee schedule,Pays 100% Medicare OPPS,5.19,90,,,fee schedule,Pays 90% Medicare OPPS,58,58,,,percent of total billed charges,58% of total billed charges,8.74,120.37,,,fee schedule,120.37% of custom fee schedule,5.77,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,130,,,fee schedule,Pays 130% Medicare OPPS,85,85,,,percent of total billed charges,85% of total billed charges,5.77,100,,,fee schedule,Pays 100% Medicare OPPS,5.19,90,
BONE MARROW PATH HANDLING,3000032,CDM,300,RC,,,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,20.37,90,
CYTOLOGY/HANDLING,3000107,CDM,300,RC,,,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,20.37,90,
"FROZEN SECTION PATH, HAND",3000115,CDM,300,RC,,,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,20.37,90,
Test for HIV,3000152,CDM,300,RC,87389,HCPCS,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,24.08,100,,,fee schedule,Pays 100% Medicare OPPS,24.08,100,,,fee schedule,Pays 100% Medicare OPPS,24.08,100,,,fee schedule,Pays 100% Medicare OPPS,31.3,130,,,fee schedule,Pays 130% Medicare OPPS,32.86,120.37,,,fee schedule,120.37% of custom fee schedule,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,24.56,102,,,fee schedule,Pays 102% Medicare OPPS,90,90,,,percent of total billed charges,90% of total billed charges,34.17,125.18,,,fee schedule,125.18% of custom fee schedule,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,24.08,100,,,fee schedule,Pays 100% Medicare OPPS,21.67,90,,,fee schedule,Pays 90% Medicare OPPS,58,58,,,percent of total billed charges,58% of total billed charges,32.86,120.37,,,fee schedule,120.37% of custom fee schedule,24.08,100,,,fee schedule,Pays 100% Medicare OPPS,31.3,130,,,fee schedule,Pays 130% Medicare OPPS,85,85,,,percent of total billed charges,85% of total billed charges,24.08,100,,,fee schedule,Pays 100% Medicare OPPS,21.67,90,
METABOLIC SCREEN,3000195,CDM,300,RC,,,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,20.37,90,
A lab test to screen for evidence of vaginal infection,3000335,CDM,306,RC,87210,HCPCS,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,7.56,130,,,fee schedule,Pays 130% Medicare OPPS,6.45,120.37,,,fee schedule,120.37% of custom fee schedule,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.93,102,,,fee schedule,Pays 102% Medicare OPPS,90,90,,,percent of total billed charges,90% of total billed charges,6.71,125.18,,,fee schedule,125.18% of custom fee schedule,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,5.23,90,,,fee schedule,Pays 90% Medicare OPPS,58,58,,,percent of total billed charges,58% of total billed charges,6.45,120.37,,,fee schedule,120.37% of custom fee schedule,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,7.56,130,,,fee schedule,Pays 130% Medicare OPPS,85,85,,,percent of total billed charges,85% of total billed charges,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,5.23,90,
BB ABO TYPE,3000380,CDM,300,RC,86900,HCPCS,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,4.51,120.37,,,fee schedule,120.37% of custom fee schedule,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,90,90,,,percent of total billed charges,90% of total billed charges,4.69,125.18,,,fee schedule,125.18% of custom fee schedule,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,58,58,,,percent of total billed charges,58% of total billed charges,4.51,120.37,,,fee schedule,120.37% of custom fee schedule,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,85,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,4.51,132.76,
.CULTURE STOOL,3000665,CDM,306,RC,87045,HCPCS,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,12.27,130,,,fee schedule,Pays 130% Medicare OPPS,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.62,102,,,fee schedule,Pays 102% Medicare OPPS,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,8.49,90,,,fee schedule,Pays 90% Medicare OPPS,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,12.27,130,,,fee schedule,Pays 130% Medicare OPPS,85,85,,,percent of total billed charges,85% of total billed charges,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,8.49,90,
.LYME IGG,3000728,CDM,302,RC,86617,HCPCS,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,15.49,100,,,fee schedule,Pays 100% Medicare OPPS,15.49,100,,,fee schedule,Pays 100% Medicare OPPS,15.49,100,,,fee schedule,Pays 100% Medicare OPPS,20.13,130,,,fee schedule,Pays 130% Medicare OPPS,23.45,120.37,,,fee schedule,120.37% of custom fee schedule,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.79,102,,,fee schedule,Pays 102% Medicare OPPS,90,90,,,percent of total billed charges,90% of total billed charges,24.39,125.18,,,fee schedule,125.18% of custom fee schedule,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,15.49,100,,,fee schedule,Pays 100% Medicare OPPS,13.94,90,,,fee schedule,Pays 90% Medicare OPPS,58,58,,,percent of total billed charges,58% of total billed charges,23.45,120.37,,,fee schedule,120.37% of custom fee schedule,15.49,100,,,fee schedule,Pays 100% Medicare OPPS,20.13,130,,,fee schedule,Pays 130% Medicare OPPS,85,85,,,percent of total billed charges,85% of total billed charges,15.49,100,,,fee schedule,Pays 100% Medicare OPPS,13.94,90,
.LYME IGM,3000729,CDM,302,RC,86617,HCPCS,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,15.49,100,,,fee schedule,Pays 100% Medicare OPPS,15.49,100,,,fee schedule,Pays 100% Medicare OPPS,15.49,100,,,fee schedule,Pays 100% Medicare OPPS,20.13,130,,,fee schedule,Pays 130% Medicare OPPS,23.45,120.37,,,fee schedule,120.37% of custom fee schedule,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.79,102,,,fee schedule,Pays 102% Medicare OPPS,90,90,,,percent of total billed charges,90% of total billed charges,24.39,125.18,,,fee schedule,125.18% of custom fee schedule,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,15.49,100,,,fee schedule,Pays 100% Medicare OPPS,13.94,90,,,fee schedule,Pays 90% Medicare OPPS,58,58,,,percent of total billed charges,58% of total billed charges,23.45,120.37,,,fee schedule,120.37% of custom fee schedule,15.49,100,,,fee schedule,Pays 100% Medicare OPPS,20.13,130,,,fee schedule,Pays 130% Medicare OPPS,85,85,,,percent of total billed charges,85% of total billed charges,15.49,100,,,fee schedule,Pays 100% Medicare OPPS,13.94,90,
EBV NUCLEAR AG IGG,3086662,CDM,302,RC,86664,HCPCS,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,15.29,100,,,fee schedule,Pays 100% Medicare OPPS,15.29,100,,,fee schedule,Pays 100% Medicare OPPS,15.29,100,,,fee schedule,Pays 100% Medicare OPPS,19.87,130,,,fee schedule,Pays 130% Medicare OPPS,23.16,120.37,,,fee schedule,120.37% of custom fee schedule,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.59,102,,,fee schedule,Pays 102% Medicare OPPS,90,90,,,percent of total billed charges,90% of total billed charges,24.08,125.18,,,fee schedule,125.18% of custom fee schedule,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,15.29,100,,,fee schedule,Pays 100% Medicare OPPS,13.76,90,,,fee schedule,Pays 90% Medicare OPPS,58,58,,,percent of total billed charges,58% of total billed charges,23.16,120.37,,,fee schedule,120.37% of custom fee schedule,15.29,100,,,fee schedule,Pays 100% Medicare OPPS,19.87,130,,,fee schedule,Pays 130% Medicare OPPS,85,85,,,percent of total billed charges,85% of total billed charges,15.29,100,,,fee schedule,Pays 100% Medicare OPPS,13.76,90,
HEP A IgM AB,3086709,CDM,302,RC,86709,HCPCS,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,11.26,100,,,fee schedule,Pays 100% Medicare OPPS,11.26,100,,,fee schedule,Pays 100% Medicare OPPS,11.26,100,,,fee schedule,Pays 100% Medicare OPPS,14.63,130,,,fee schedule,Pays 130% Medicare OPPS,17.04,120.37,,,fee schedule,120.37% of custom fee schedule,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.48,102,,,fee schedule,Pays 102% Medicare OPPS,90,90,,,percent of total billed charges,90% of total billed charges,17.73,125.18,,,fee schedule,125.18% of custom fee schedule,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,11.26,100,,,fee schedule,Pays 100% Medicare OPPS,10.13,90,,,fee schedule,Pays 90% Medicare OPPS,58,58,,,percent of total billed charges,58% of total billed charges,17.04,120.37,,,fee schedule,120.37% of custom fee schedule,11.26,100,,,fee schedule,Pays 100% Medicare OPPS,14.63,130,,,fee schedule,Pays 130% Medicare OPPS,85,85,,,percent of total billed charges,85% of total billed charges,11.26,100,,,fee schedule,Pays 100% Medicare OPPS,10.13,90,
KOH PREP,3087220,CDM,306,RC,87220,HCPCS,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,5.55,130,,,fee schedule,Pays 130% Medicare OPPS,6.45,120.37,,,fee schedule,120.37% of custom fee schedule,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.35,102,,,fee schedule,Pays 102% Medicare OPPS,90,90,,,percent of total billed charges,90% of total billed charges,6.71,125.18,,,fee schedule,125.18% of custom fee schedule,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,3.84,90,,,fee schedule,Pays 90% Medicare OPPS,58,58,,,percent of total billed charges,58% of total billed charges,6.45,120.37,,,fee schedule,120.37% of custom fee schedule,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,5.55,130,,,fee schedule,Pays 130% Medicare OPPS,85,85,,,percent of total billed charges,85% of total billed charges,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,3.84,90,
.CANDIDA DNA AMP PROBE,3087481,CDM,302,RC,87481,HCPCS,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,,,fee schedule,Pays 130% Medicare OPPS,29.7,120.37,,,fee schedule,120.37% of custom fee schedule,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,35.79,102,,,fee schedule,Pays 102% Medicare OPPS,90,90,,,percent of total billed charges,90% of total billed charges,30.88,125.18,,,fee schedule,125.18% of custom fee schedule,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,31.58,90,,,fee schedule,Pays 90% Medicare OPPS,58,58,,,percent of total billed charges,58% of total billed charges,29.7,120.37,,,fee schedule,120.37% of custom fee schedule,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,,,fee schedule,Pays 130% Medicare OPPS,85,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,29.7,90,
.STAPH A DNA AMP PROBE,3087640,CDM,302,RC,87640,HCPCS,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,,,fee schedule,Pays 130% Medicare OPPS,29.7,120.37,,,fee schedule,120.37% of custom fee schedule,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,35.79,102,,,fee schedule,Pays 102% Medicare OPPS,90,90,,,percent of total billed charges,90% of total billed charges,30.88,125.18,,,fee schedule,125.18% of custom fee schedule,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,31.58,90,,,fee schedule,Pays 90% Medicare OPPS,58,58,,,percent of total billed charges,58% of total billed charges,29.7,120.37,,,fee schedule,120.37% of custom fee schedule,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,,,fee schedule,Pays 130% Medicare OPPS,85,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,29.7,90,
Blood test for strep infection,3087653,CDM,302,RC,87653,HCPCS,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,,,fee schedule,Pays 130% Medicare OPPS,29.7,120.37,,,fee schedule,120.37% of custom fee schedule,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,35.79,102,,,fee schedule,Pays 102% Medicare OPPS,90,90,,,percent of total billed charges,90% of total billed charges,30.88,125.18,,,fee schedule,125.18% of custom fee schedule,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,31.58,90,,,fee schedule,Pays 90% Medicare OPPS,58,58,,,percent of total billed charges,58% of total billed charges,29.7,120.37,,,fee schedule,120.37% of custom fee schedule,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,,,fee schedule,Pays 130% Medicare OPPS,85,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,29.7,90,
.DETECT AGENT DNA PROBE,3087789,CDM,302,RC,87798,HCPCS,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,,,fee schedule,Pays 130% Medicare OPPS,29.7,120.37,,,fee schedule,120.37% of custom fee schedule,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,35.79,102,,,fee schedule,Pays 102% Medicare OPPS,90,90,,,percent of total billed charges,90% of total billed charges,30.88,125.18,,,fee schedule,125.18% of custom fee schedule,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,31.58,90,,,fee schedule,Pays 90% Medicare OPPS,58,58,,,percent of total billed charges,58% of total billed charges,29.7,120.37,,,fee schedule,120.37% of custom fee schedule,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,,,fee schedule,Pays 130% Medicare OPPS,85,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,29.7,90,
PAP smear,3088142,CDM,300,RC,88142,HCPCS,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,20.26,100,,,fee schedule,Pays 100% Medicare OPPS,20.26,100,,,fee schedule,Pays 100% Medicare OPPS,20.26,100,,,fee schedule,Pays 100% Medicare OPPS,26.33,130,,,fee schedule,Pays 130% Medicare OPPS,30.67,120.37,,,fee schedule,120.37% of custom fee schedule,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,20.66,102,,,fee schedule,Pays 102% Medicare OPPS,90,90,,,percent of total billed charges,90% of total billed charges,31.9,125.18,,,fee schedule,125.18% of custom fee schedule,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,20.26,100,,,fee schedule,Pays 100% Medicare OPPS,18.23,90,,,fee schedule,Pays 90% Medicare OPPS,58,58,,,percent of total billed charges,58% of total billed charges,30.67,120.37,,,fee schedule,120.37% of custom fee schedule,20.26,100,,,fee schedule,Pays 100% Medicare OPPS,26.33,130,,,fee schedule,Pays 130% Medicare OPPS,85,85,,,percent of total billed charges,85% of total billed charges,20.26,100,,,fee schedule,Pays 100% Medicare OPPS,18.23,90,
PATHOLOGY/HANDLING,3200001,CDM,270,RC,,,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,20.37,90,
INSERTION UMBILICAL ARTERY,4036660,CDM,721,RC,36660,HCPCS,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,100,100,,,fee schedule,Pays 100% Medicare OPPS,100,100,,,fee schedule,Pays 100% Medicare OPPS,100,100,,,fee schedule,Pays 100% Medicare OPPS,100,130,,,fee schedule,Pays 130% Medicare OPPS,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,100,102,,,fee schedule,Pays 102% Medicare OPPS,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,100,100,,,fee schedule,Pays 100% Medicare OPPS,100,90,,,fee schedule,Pays 90% Medicare OPPS,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,100,100,,,fee schedule,Pays 100% Medicare OPPS,100,130,,,fee schedule,Pays 130% Medicare OPPS,85,85,,,percent of total billed charges,85% of total billed charges,100,100,,,fee schedule,Pays 100% Medicare OPPS,20.37,100,
COPY FILM PER MRI/CT/US EXAM,4600803,CDM,270,RC,,,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,20.37,90,
"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",5007035,CDM,420,RC,97035,HCPCS,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,13.65,100,,,fee schedule,Pays 100% Medicare OPPS,13.65,100,,,fee schedule,Pays 100% Medicare OPPS,13.65,100,,,fee schedule,Pays 100% Medicare OPPS,17.84,130,,,fee schedule,Pays 130% Medicare OPPS,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.92,102,,,fee schedule,Pays 102% Medicare OPPS,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,13.65,100,,,fee schedule,Pays 100% Medicare OPPS,12.29,90,,,fee schedule,Pays 90% Medicare OPPS,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,13.72,100,,,fee schedule,Pays 100% Medicare OPPS,17.84,130,,,fee schedule,Pays 130% Medicare OPPS,85,85,,,percent of total billed charges,85% of total billed charges,13.65,100,,,fee schedule,Pays 100% Medicare OPPS,12.29,90,
Light-based method to treat pain and inflammation,5097026,CDM,420,RC,97026,HCPCS,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,6.03,100,,,fee schedule,Pays 100% Medicare OPPS,6.03,100,,,fee schedule,Pays 100% Medicare OPPS,6.03,100,,,fee schedule,Pays 100% Medicare OPPS,8.13,130,,,fee schedule,Pays 130% Medicare OPPS,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.15,102,,,fee schedule,Pays 102% Medicare OPPS,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,6.03,100,,,fee schedule,Pays 100% Medicare OPPS,5.43,90,,,fee schedule,Pays 90% Medicare OPPS,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,6.25,100,,,fee schedule,Pays 100% Medicare OPPS,8.13,130,,,fee schedule,Pays 130% Medicare OPPS,85,85,,,percent of total billed charges,85% of total billed charges,6.03,100,,,fee schedule,Pays 100% Medicare OPPS,5.43,90,
"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",5097035,CDM,420,RC,97035,HCPCS,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,13.65,100,,,fee schedule,Pays 100% Medicare OPPS,13.65,100,,,fee schedule,Pays 100% Medicare OPPS,13.65,100,,,fee schedule,Pays 100% Medicare OPPS,17.84,130,,,fee schedule,Pays 130% Medicare OPPS,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.92,102,,,fee schedule,Pays 102% Medicare OPPS,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,13.65,100,,,fee schedule,Pays 100% Medicare OPPS,12.29,90,,,fee schedule,Pays 90% Medicare OPPS,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,13.72,100,,,fee schedule,Pays 100% Medicare OPPS,17.84,130,,,fee schedule,Pays 130% Medicare OPPS,85,85,,,percent of total billed charges,85% of total billed charges,13.65,100,,,fee schedule,Pays 100% Medicare OPPS,12.29,90,
Use of massage,5097154,CDM,420,RC,97124,HCPCS,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,28.22,100,,,fee schedule,Pays 100% Medicare OPPS,28.22,100,,,fee schedule,Pays 100% Medicare OPPS,28.22,100,,,fee schedule,Pays 100% Medicare OPPS,36.82,130,,,fee schedule,Pays 130% Medicare OPPS,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.78,102,,,fee schedule,Pays 102% Medicare OPPS,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,28.22,100,,,fee schedule,Pays 100% Medicare OPPS,25.4,90,,,fee schedule,Pays 90% Medicare OPPS,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.32,100,,,fee schedule,Pays 100% Medicare OPPS,36.82,130,,,fee schedule,Pays 130% Medicare OPPS,85,85,,,percent of total billed charges,85% of total billed charges,28.22,100,,,fee schedule,Pays 100% Medicare OPPS,20.37,90,
"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",5197035,CDM,430,RC,97035,HCPCS,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,13.65,100,,,fee schedule,Pays 100% Medicare OPPS,13.65,100,,,fee schedule,Pays 100% Medicare OPPS,13.65,100,,,fee schedule,Pays 100% Medicare OPPS,17.84,130,,,fee schedule,Pays 130% Medicare OPPS,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.92,102,,,fee schedule,Pays 102% Medicare OPPS,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,13.65,100,,,fee schedule,Pays 100% Medicare OPPS,12.29,90,,,fee schedule,Pays 90% Medicare OPPS,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,13.72,100,,,fee schedule,Pays 100% Medicare OPPS,17.84,130,,,fee schedule,Pays 130% Medicare OPPS,85,85,,,percent of total billed charges,85% of total billed charges,13.65,100,,,fee schedule,Pays 100% Medicare OPPS,12.29,90,
Use of massage,5197124,CDM,430,RC,97124,HCPCS,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,28.22,100,,,fee schedule,Pays 100% Medicare OPPS,28.22,100,,,fee schedule,Pays 100% Medicare OPPS,28.22,100,,,fee schedule,Pays 100% Medicare OPPS,36.82,130,,,fee schedule,Pays 130% Medicare OPPS,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.78,102,,,fee schedule,Pays 102% Medicare OPPS,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,28.22,100,,,fee schedule,Pays 100% Medicare OPPS,25.4,90,,,fee schedule,Pays 90% Medicare OPPS,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.32,100,,,fee schedule,Pays 100% Medicare OPPS,36.82,130,,,fee schedule,Pays 130% Medicare OPPS,85,85,,,percent of total billed charges,85% of total billed charges,28.22,100,,,fee schedule,Pays 100% Medicare OPPS,20.37,90,
ARTERIAL PUNCTURE,5536600,CDM,410,RC,36600,HCPCS,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,85,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,20.37,132.76,
ROOM HUMIDIFIER,5550022,CDM,270,RC,,,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,20.37,90,
BABY PACK C SECTION,7901194,CDM,270,RC,,,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,20.37,90,
BASIC ORTHO INST SET,7901198,CDM,270,RC,,,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,20.37,90,
HAND TRAY,7901202,CDM,270,RC,,,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,20.37,90,
ANKLE BRACE AIRCAST RT (FIT/ADJ),7905123,CDM,274,RC,L4350,HCPCS,Both,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,20.37,90,
FLOWTRON GARMENT LG,7905286,CDM,270,RC,,,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,20.37,90,
TRACHEAL TUBE ORAL,7905736,CDM,270,RC,,,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,20.37,90,
CATH CHOLANGIOGRAPY SET,7905792,CDM,270,RC,,,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,20.37,90,
NEEDLE INTRAOSSEOUS CAREFUSION DIN1515X,7905938,CDM,272,RC,,,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,20.37,90,
ENDO TRACH TUBE,7919401,CDM,272,RC,,,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,20.37,90,
CURETTE ENDOMETRIAL SUCT.,7950028,CDM,270,RC,,,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,20.37,90,
STETHOSCOPE ESOPHAGEAL,7950059,CDM,272,RC,,,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,20.37,90,
ENDOPATH STABILITY SLEEVE CB5LT,7950185,CDM,272,RC,,,Outpatient,,,100,80,,85,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,90,90,,,percent of total billed charges,90% of total billed charges,35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,68.7,68.7,,,percent of total billed charges,68.7% of total billed charges,80,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,58,58,,,percent of total billed charges,58% of total billed charges,20.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,20.37,90,
J VAC RESERVOIR,7905738,CDM,272,RC,,,Outpatient,,,102,81.6,,86.7,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,20.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,57.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,57.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,57.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,57.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,91.8,90,,,percent of total billed charges,90% of total billed charges,35.7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,70.07,68.7,,,percent of total billed charges,68.7% of total billed charges,81.6,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,59.16,58,,,percent of total billed charges,58% of total billed charges,20.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,86.7,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,20.78,91.8,
Injection to treat reaction to a drug,2601278,CDM,636,RC,J0702,HCPCS,Both,,,105,84,,89.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.21,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,94.5,90,,,percent of total billed charges,90% of total billed charges,8.54,125.18,,,fee schedule,125.18% of custom fee schedule,72.14,68.7,,,percent of total billed charges,68.7% of total billed charges,84,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,60.9,58,,,percent of total billed charges,58% of total billed charges,8.21,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,89.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.21,94.5,
XYLO PUDENDAL SYRINGE INJ 30ML,2601435,CDM,636,RC,,,Both,,,105,84,,89.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,94.5,90,,,percent of total billed charges,90% of total billed charges,36.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,72.14,68.7,,,percent of total billed charges,68.7% of total billed charges,84,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,60.9,58,,,percent of total billed charges,58% of total billed charges,21.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,89.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,21.39,94.5,
LIPOSYN 10% (LIPID EMULSION) IV : 1ML,2610068,CDM,250,RC,,,Outpatient,,,105,84,,89.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,59.33,56.5,,,percent of total billed charges,56.5 percent of total billed charges,59.33,56.5,,,percent of total billed charges,56.5 percent of total billed charges,59.33,56.5,,,percent of total billed charges,56.5 percent of total billed charges,59.33,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,94.5,90,,,percent of total billed charges,90% of total billed charges,36.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,72.14,68.7,,,percent of total billed charges,68.7% of total billed charges,84,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,60.9,58,,,percent of total billed charges,58% of total billed charges,21.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,89.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,21.39,94.5,
CLOG ZAPPER,2610134,CDM,270,RC,,,Outpatient,,,107.23,85.78,,91.15,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.84,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,60.58,56.5,,,percent of total billed charges,56.5 percent of total billed charges,60.58,56.5,,,percent of total billed charges,56.5 percent of total billed charges,60.58,56.5,,,percent of total billed charges,56.5 percent of total billed charges,60.58,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,96.51,90,,,percent of total billed charges,90% of total billed charges,37.53,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,73.67,68.7,,,percent of total billed charges,68.7% of total billed charges,85.78,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,62.19,58,,,percent of total billed charges,58% of total billed charges,21.84,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,91.15,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,21.84,96.51,
HEARING SCREENING/NEWBORN,500001,CDM,479,RC,92587,HCPCS,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,320.22,130,,,fee schedule,Pays 130% Medicare OPPS,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,242.49,102,,,fee schedule,Pays 102% Medicare OPPS,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,213.96,90,,,fee schedule,Pays 90% Medicare OPPS,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,246.33,100,,,fee schedule,Pays 100% Medicare OPPS,320.22,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,22.41,320.22,
HEARING SCREENING/NEWBORN,501157,CDM,479,RC,92585,HCPCS,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,22.41,99,
SCREW BONE 3.5MM LOCKING SELF TAP 45MM,1570024,CDM,278,RC,C1713,HCPCS,Both,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
K-WIRE 1.3 FOR 4.0 CANNULATED SCREW,1570353,CDM,278,RC,C1713,HCPCS,Both,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
SUTURE 3-0 ETHILON 1663H,1570548,CDM,272,RC,,,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
CULDESAC PUNCTURE,2005022,CDM,450,RC,,,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
EPOGEN 1000 UNITS (</= 10000 UNITS),2600020,CDM,636,RC,J0885,HCPCS,Both,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,8.36,100,,,fee schedule,Pays 100% Medicare OPPS,8.36,100,,,fee schedule,Pays 100% Medicare OPPS,8.36,100,,,fee schedule,Pays 100% Medicare OPPS,9.21,130,,,fee schedule,Pays 130% Medicare OPPS,10.07,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.52,102,,,fee schedule,Pays 102% Medicare OPPS,99,90,,,percent of total billed charges,90% of total billed charges,10.48,125.18,,,fee schedule,125.18% of custom fee schedule,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,8.36,100,,,fee schedule,Pays 100% Medicare OPPS,7.53,90,,,fee schedule,Pays 90% Medicare OPPS,63.8,58,,,percent of total billed charges,58% of total billed charges,10.07,120.37,,,fee schedule,120.37% of custom fee schedule,7.09,100,,,fee schedule,Pays 100% Medicare OPPS,9.21,130,,,fee schedule,Pays 130% Medicare OPPS,93.5,85,,,percent of total billed charges,85% of total billed charges,8.36,100,,,fee schedule,Pays 100% Medicare OPPS,7.09,99,
DEBROX EAR DROPS 15ML,2600102,CDM,637,RC,,,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
ZOSYN INJ 2.25GM,2600133,CDM,250,RC,,,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
LABOR/DELIVERY KIT,2600158,CDM,636,RC,J2590,HCPCS,Both,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
VIBRAMYCIN (DOXYCYCLINE) INJ 100MG,2601055,CDM,636,RC,,,Both,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
FORTAZ (CEFTAZIDIME) INJ 1GM,2601171,CDM,636,RC,J0713,HCPCS,Both,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
FORTAZ (CEFTAZIDIME) INJ 2GM,2601172,CDM,636,RC,,,Both,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
ADENOCARD (ADENOSINE) INJ : 6MG,2601345,CDM,636,RC,,,Both,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
MUMPS SKIN TEST INJ : 0.1ML,2601398,CDM,250,RC,,,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
VISTARIL (HYDROXYZINE HCL) 50MG IM INJ,2601416,CDM,636,RC,J3410,HCPCS,Both,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,13.65,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,14.2,125.18,,,fee schedule,125.18% of custom fee schedule,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,13.65,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.65,99,
BENTYL (DICYCLOMINE HCL) INJ 20MG,2602534,CDM,636,RC,J0500,HCPCS,Both,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,30.86,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,32.1,125.18,,,fee schedule,125.18% of custom fee schedule,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,30.86,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,30.86,99,
Preservative free flu vaccine,2605002,CDM,636,RC,90658,HCPCS,Both,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
D5W/KCL 40 MEQ IV SOLN 1000ML,2610040,CDM,250,RC,,,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
HUBER NEEDLE W/ EXT 20GAX1.5 INCH,2611000,CDM,270,RC,,,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
ADMIN 2ND MODERNA DOSE COVID19 VACCINE,2611112,CDM,771,RC,0012A,HCPCS,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,35.88,102,,,fee schedule,Pays 102% Medicare OPPS,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,31.66,90,,,fee schedule,Pays 90% Medicare OPPS,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,22.41,99,
SODIUM CHLORIDE 5% IV SOLN 500ML,2612002,CDM,250,RC,,,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
CLEOCIN 600MG/50ML IVPB PREMIX,2630003,CDM,250,RC,,,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
Blood test to determine autoimmune disorders,3000010,CDM,302,RC,86039,HCPCS,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,11.16,100,,,fee schedule,Pays 100% Medicare OPPS,11.16,100,,,fee schedule,Pays 100% Medicare OPPS,11.16,100,,,fee schedule,Pays 100% Medicare OPPS,14.5,130,,,fee schedule,Pays 130% Medicare OPPS,16.9,120.37,,,fee schedule,120.37% of custom fee schedule,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.38,102,,,fee schedule,Pays 102% Medicare OPPS,99,90,,,percent of total billed charges,90% of total billed charges,17.58,125.18,,,fee schedule,125.18% of custom fee schedule,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,11.16,100,,,fee schedule,Pays 100% Medicare OPPS,10.04,90,,,fee schedule,Pays 90% Medicare OPPS,63.8,58,,,percent of total billed charges,58% of total billed charges,16.9,120.37,,,fee schedule,120.37% of custom fee schedule,11.16,100,,,fee schedule,Pays 100% Medicare OPPS,14.5,130,,,fee schedule,Pays 130% Medicare OPPS,93.5,85,,,percent of total billed charges,85% of total billed charges,11.16,100,,,fee schedule,Pays 100% Medicare OPPS,10.04,99,
A lab test to screen for evidence of vaginal infection,3000169,CDM,306,RC,87210,HCPCS,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,7.56,130,,,fee schedule,Pays 130% Medicare OPPS,6.45,120.37,,,fee schedule,120.37% of custom fee schedule,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.93,102,,,fee schedule,Pays 102% Medicare OPPS,99,90,,,percent of total billed charges,90% of total billed charges,6.71,125.18,,,fee schedule,125.18% of custom fee schedule,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,5.23,90,,,fee schedule,Pays 90% Medicare OPPS,63.8,58,,,percent of total billed charges,58% of total billed charges,6.45,120.37,,,fee schedule,120.37% of custom fee schedule,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,7.56,130,,,fee schedule,Pays 130% Medicare OPPS,93.5,85,,,percent of total billed charges,85% of total billed charges,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,5.23,99,
.SSA/SSB (SJOGREN'S AB),3000290,CDM,302,RC,86235,HCPCS,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.28,102,,,fee schedule,Pays 102% Medicare OPPS,99,90,,,percent of total billed charges,90% of total billed charges,28.23,125.18,,,fee schedule,125.18% of custom fee schedule,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,90,,,fee schedule,Pays 90% Medicare OPPS,63.8,58,,,percent of total billed charges,58% of total billed charges,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,93.5,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,99,
Test to determine levels of immunoglobulins in the blood,3000309,CDM,301,RC,82784,HCPCS,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,12.09,130,,,fee schedule,Pays 130% Medicare OPPS,14.07,120.37,,,fee schedule,120.37% of custom fee schedule,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.48,102,,,fee schedule,Pays 102% Medicare OPPS,99,90,,,percent of total billed charges,90% of total billed charges,14.63,125.18,,,fee schedule,125.18% of custom fee schedule,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,8.37,90,,,fee schedule,Pays 90% Medicare OPPS,63.8,58,,,percent of total billed charges,58% of total billed charges,14.07,120.37,,,fee schedule,120.37% of custom fee schedule,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,12.09,130,,,fee schedule,Pays 130% Medicare OPPS,93.5,85,,,percent of total billed charges,85% of total billed charges,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,8.37,99,
.PL-7 AUTOABS,3000617,CDM,302,RC,86235,HCPCS,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.28,102,,,fee schedule,Pays 102% Medicare OPPS,99,90,,,percent of total billed charges,90% of total billed charges,28.23,125.18,,,fee schedule,125.18% of custom fee schedule,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,90,,,fee schedule,Pays 90% Medicare OPPS,63.8,58,,,percent of total billed charges,58% of total billed charges,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,93.5,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,99,
Chemical test of the blood to measure presence or concentration of a substance in the blood,3000618,CDM,302,RC,83516,HCPCS,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.76,102,,,fee schedule,Pays 102% Medicare OPPS,99,90,,,percent of total billed charges,90% of total billed charges,16.84,125.18,,,fee schedule,125.18% of custom fee schedule,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,90,,,fee schedule,Pays 90% Medicare OPPS,63.8,58,,,percent of total billed charges,58% of total billed charges,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,93.5,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,99,
Chemical test of the blood to measure presence or concentration of a substance in the blood,3000619,CDM,302,RC,83516,HCPCS,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.76,102,,,fee schedule,Pays 102% Medicare OPPS,99,90,,,percent of total billed charges,90% of total billed charges,16.84,125.18,,,fee schedule,125.18% of custom fee schedule,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,90,,,fee schedule,Pays 90% Medicare OPPS,63.8,58,,,percent of total billed charges,58% of total billed charges,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,93.5,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,99,
Chemical test of the blood to measure presence or concentration of a substance in the blood,3000620,CDM,302,RC,83516,HCPCS,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.76,102,,,fee schedule,Pays 102% Medicare OPPS,99,90,,,percent of total billed charges,90% of total billed charges,16.84,125.18,,,fee schedule,125.18% of custom fee schedule,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,90,,,fee schedule,Pays 90% Medicare OPPS,63.8,58,,,percent of total billed charges,58% of total billed charges,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,93.5,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,99,
Chemical test of the blood to measure presence or concentration of a substance in the blood,3000621,CDM,302,RC,83516,HCPCS,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.76,102,,,fee schedule,Pays 102% Medicare OPPS,99,90,,,percent of total billed charges,90% of total billed charges,16.84,125.18,,,fee schedule,125.18% of custom fee schedule,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,90,,,fee schedule,Pays 90% Medicare OPPS,63.8,58,,,percent of total billed charges,58% of total billed charges,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,93.5,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,99,
.RENIN,3000674,CDM,302,RC,84244,HCPCS,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,21.99,100,,,fee schedule,Pays 100% Medicare OPPS,21.99,100,,,fee schedule,Pays 100% Medicare OPPS,21.99,100,,,fee schedule,Pays 100% Medicare OPPS,28.58,130,,,fee schedule,Pays 130% Medicare OPPS,33.29,120.37,,,fee schedule,120.37% of custom fee schedule,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.42,102,,,fee schedule,Pays 102% Medicare OPPS,99,90,,,percent of total billed charges,90% of total billed charges,34.62,125.18,,,fee schedule,125.18% of custom fee schedule,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,21.99,100,,,fee schedule,Pays 100% Medicare OPPS,19.79,90,,,fee schedule,Pays 90% Medicare OPPS,63.8,58,,,percent of total billed charges,58% of total billed charges,33.29,120.37,,,fee schedule,120.37% of custom fee schedule,21.99,100,,,fee schedule,Pays 100% Medicare OPPS,28.58,130,,,fee schedule,Pays 130% Medicare OPPS,93.5,85,,,percent of total billed charges,85% of total billed charges,21.99,100,,,fee schedule,Pays 100% Medicare OPPS,19.79,99,
.KAPPA/LAMBA,3000732,CDM,302,RC,83883,HCPCS,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,13.6,100,,,fee schedule,Pays 100% Medicare OPPS,13.6,100,,,fee schedule,Pays 100% Medicare OPPS,13.6,100,,,fee schedule,Pays 100% Medicare OPPS,17.68,130,,,fee schedule,Pays 130% Medicare OPPS,20.58,120.37,,,fee schedule,120.37% of custom fee schedule,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.87,102,,,fee schedule,Pays 102% Medicare OPPS,99,90,,,percent of total billed charges,90% of total billed charges,21.41,125.18,,,fee schedule,125.18% of custom fee schedule,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,13.6,100,,,fee schedule,Pays 100% Medicare OPPS,12.24,90,,,fee schedule,Pays 90% Medicare OPPS,63.8,58,,,percent of total billed charges,58% of total billed charges,20.58,120.37,,,fee schedule,120.37% of custom fee schedule,13.6,100,,,fee schedule,Pays 100% Medicare OPPS,17.68,130,,,fee schedule,Pays 130% Medicare OPPS,93.5,85,,,percent of total billed charges,85% of total billed charges,13.6,100,,,fee schedule,Pays 100% Medicare OPPS,12.24,99,
POSITIVE ANCA TITER,3000740,CDM,302,RC,86021,HCPCS,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,15.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.05,100,,,fee schedule,Pays 100% Medicare OPPS,19.56,130,,,fee schedule,Pays 130% Medicare OPPS,22.79,120.37,,,fee schedule,120.37% of custom fee schedule,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.35,102,,,fee schedule,Pays 102% Medicare OPPS,99,90,,,percent of total billed charges,90% of total billed charges,23.7,125.18,,,fee schedule,125.18% of custom fee schedule,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,15.05,100,,,fee schedule,Pays 100% Medicare OPPS,13.54,90,,,fee schedule,Pays 90% Medicare OPPS,63.8,58,,,percent of total billed charges,58% of total billed charges,22.79,120.37,,,fee schedule,120.37% of custom fee schedule,15.05,100,,,fee schedule,Pays 100% Medicare OPPS,19.56,130,,,fee schedule,Pays 130% Medicare OPPS,93.5,85,,,percent of total billed charges,85% of total billed charges,15.05,100,,,fee schedule,Pays 100% Medicare OPPS,13.54,99,
.IMMUNO G (IgG SUBCLASSES,3082787,CDM,301,RC,82787,HCPCS,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,8.02,100,,,fee schedule,Pays 100% Medicare OPPS,8.02,100,,,fee schedule,Pays 100% Medicare OPPS,8.02,100,,,fee schedule,Pays 100% Medicare OPPS,10.42,130,,,fee schedule,Pays 130% Medicare OPPS,12.13,120.37,,,fee schedule,120.37% of custom fee schedule,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.18,102,,,fee schedule,Pays 102% Medicare OPPS,99,90,,,percent of total billed charges,90% of total billed charges,12.62,125.18,,,fee schedule,125.18% of custom fee schedule,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,8.02,100,,,fee schedule,Pays 100% Medicare OPPS,7.21,90,,,fee schedule,Pays 90% Medicare OPPS,63.8,58,,,percent of total billed charges,58% of total billed charges,12.13,120.37,,,fee schedule,120.37% of custom fee schedule,8.02,100,,,fee schedule,Pays 100% Medicare OPPS,10.42,130,,,fee schedule,Pays 130% Medicare OPPS,93.5,85,,,percent of total billed charges,85% of total billed charges,8.02,100,,,fee schedule,Pays 100% Medicare OPPS,7.21,99,
3RD CYSTIC FIBROSIS BUCAL SME,3083898,CDM,301,RC,81223,HCPCS,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,499,100,,,fee schedule,Pays 100% Medicare OPPS,499,100,,,fee schedule,Pays 100% Medicare OPPS,499,100,,,fee schedule,Pays 100% Medicare OPPS,648.7,130,,,fee schedule,Pays 130% Medicare OPPS,1155.55,120.37,,,fee schedule,120.37% of custom fee schedule,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,508.98,102,,,fee schedule,Pays 102% Medicare OPPS,99,90,,,percent of total billed charges,90% of total billed charges,1201.73,125.18,,,fee schedule,125.18% of custom fee schedule,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,499,100,,,fee schedule,Pays 100% Medicare OPPS,449.1,90,,,fee schedule,Pays 90% Medicare OPPS,63.8,58,,,percent of total billed charges,58% of total billed charges,1155.55,120.37,,,fee schedule,120.37% of custom fee schedule,499,100,,,fee schedule,Pays 100% Medicare OPPS,648.7,130,,,fee schedule,Pays 130% Medicare OPPS,93.5,85,,,percent of total billed charges,85% of total billed charges,499,100,,,fee schedule,Pays 100% Medicare OPPS,62.15,1201.73,
PLATELET COUNT(AUTOMATED),3085049,CDM,305,RC,85049,HCPCS,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,4.48,100,,,fee schedule,Pays 100% Medicare OPPS,4.48,100,,,fee schedule,Pays 100% Medicare OPPS,4.48,100,,,fee schedule,Pays 100% Medicare OPPS,5.82,130,,,fee schedule,Pays 130% Medicare OPPS,6.78,120.37,,,fee schedule,120.37% of custom fee schedule,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.56,102,,,fee schedule,Pays 102% Medicare OPPS,99,90,,,percent of total billed charges,90% of total billed charges,7.05,125.18,,,fee schedule,125.18% of custom fee schedule,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,4.48,100,,,fee schedule,Pays 100% Medicare OPPS,4.03,90,,,fee schedule,Pays 90% Medicare OPPS,63.8,58,,,percent of total billed charges,58% of total billed charges,6.78,120.37,,,fee schedule,120.37% of custom fee schedule,4.48,100,,,fee schedule,Pays 100% Medicare OPPS,5.82,130,,,fee schedule,Pays 130% Medicare OPPS,93.5,85,,,percent of total billed charges,85% of total billed charges,4.48,100,,,fee schedule,Pays 100% Medicare OPPS,4.03,99,
UNUSUAL SLIDE/PATH READ,3085060,CDM,305,RC,85060,HCPCS,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,31.26,120.37,,,fee schedule,120.37% of custom fee schedule,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,32.51,125.18,,,fee schedule,125.18% of custom fee schedule,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,31.26,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,31.26,99,
HEP B CORE IgM AB,3086705,CDM,302,RC,86705,HCPCS,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,11.77,100,,,fee schedule,Pays 100% Medicare OPPS,11.77,100,,,fee schedule,Pays 100% Medicare OPPS,11.77,100,,,fee schedule,Pays 100% Medicare OPPS,15.3,130,,,fee schedule,Pays 130% Medicare OPPS,17.81,120.37,,,fee schedule,120.37% of custom fee schedule,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12,102,,,fee schedule,Pays 102% Medicare OPPS,99,90,,,percent of total billed charges,90% of total billed charges,18.53,125.18,,,fee schedule,125.18% of custom fee schedule,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,11.77,100,,,fee schedule,Pays 100% Medicare OPPS,10.59,90,,,fee schedule,Pays 90% Medicare OPPS,63.8,58,,,percent of total billed charges,58% of total billed charges,17.81,120.37,,,fee schedule,120.37% of custom fee schedule,11.77,100,,,fee schedule,Pays 100% Medicare OPPS,15.3,130,,,fee schedule,Pays 130% Medicare OPPS,93.5,85,,,percent of total billed charges,85% of total billed charges,11.77,100,,,fee schedule,Pays 100% Medicare OPPS,10.59,99,
RC AG SCREEN WITH PT SERUM PER UNIT,3086904,CDM,300,RC,86904,HCPCS,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,38.83,130,,,fee schedule,Pays 130% Medicare OPPS,14.38,120.37,,,fee schedule,120.37% of custom fee schedule,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.01,102,,,fee schedule,Pays 102% Medicare OPPS,99,90,,,percent of total billed charges,90% of total billed charges,14.96,125.18,,,fee schedule,125.18% of custom fee schedule,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,27.36,90,,,fee schedule,Pays 90% Medicare OPPS,63.8,58,,,percent of total billed charges,58% of total billed charges,14.38,120.37,,,fee schedule,120.37% of custom fee schedule,29.87,100,,,fee schedule,Pays 100% Medicare OPPS,38.83,130,,,fee schedule,Pays 130% Medicare OPPS,93.5,85,,,percent of total billed charges,85% of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,14.38,99,
3RD WBC COUNT STOOL/LACTOFERRIN,3089055,CDM,300,RC,83630,HCPCS,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,19.7,100,,,fee schedule,Pays 100% Medicare OPPS,19.7,100,,,fee schedule,Pays 100% Medicare OPPS,19.7,100,,,fee schedule,Pays 100% Medicare OPPS,25.61,130,,,fee schedule,Pays 130% Medicare OPPS,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,20.09,102,,,fee schedule,Pays 102% Medicare OPPS,99,90,,,percent of total billed charges,90% of total billed charges,16.84,125.18,,,fee schedule,125.18% of custom fee schedule,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,19.7,100,,,fee schedule,Pays 100% Medicare OPPS,17.73,90,,,fee schedule,Pays 90% Medicare OPPS,63.8,58,,,percent of total billed charges,58% of total billed charges,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,19.7,100,,,fee schedule,Pays 100% Medicare OPPS,25.61,130,,,fee schedule,Pays 130% Medicare OPPS,93.5,85,,,percent of total billed charges,85% of total billed charges,19.7,100,,,fee schedule,Pays 100% Medicare OPPS,16.19,99,
.SPERM COUNT-POST VAS,3089321,CDM,309,RC,89321,HCPCS,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,,,fee schedule,Pays 130% Medicare OPPS,8.73,120.37,,,fee schedule,120.37% of custom fee schedule,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.29,102,,,fee schedule,Pays 102% Medicare OPPS,99,90,,,percent of total billed charges,90% of total billed charges,9.08,125.18,,,fee schedule,125.18% of custom fee schedule,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,10.84,90,,,fee schedule,Pays 90% Medicare OPPS,63.8,58,,,percent of total billed charges,58% of total billed charges,8.73,120.37,,,fee schedule,120.37% of custom fee schedule,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,8.73,99,
CPT (CHEST PHYSIO THER SUBSEQU),5594668,CDM,410,RC,94668,HCPCS,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,93.5,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,22.41,132.76,
BIPAP CAP MASK MEDIUM 1072622,7900025,CDM,272,RC,A7027,HCPCS,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
RIB BELT FEMALE ALL,7905308,CDM,270,RC,,,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
LUMBAR PUNCTURE TRAY SPINA 4301CSP,7905413,CDM,270,RC,,,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
NU-GAUZE 2 IODOFORM 8758,7905531,CDM,272,RC,,,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
DELIVERY RM PK III,7905568,CDM,270,RC,,,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
**DO NOT USE***,7905621,CDM,272,RC,,,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
ACE BANDAGE 4 STERILE,7905681,CDM,270,RC,,,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
ACE BANDAGE 6 STERILE,7905682,CDM,270,RC,,,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
LUMBO SACRAL SUPPORT SM,7905774,CDM,270,RC,,,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
LUMBO SACRAL SUPPORT MED,7905775,CDM,270,RC,,,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
LUMBO SACRAL SUPPORT XL,7905777,CDM,270,RC,,,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
OP SITE 11 X 11,7905809,CDM,270,RC,,,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
***DO NOT USE***,7905985,CDM,270,RC,,,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
BIPAP FACE MASK SMALL 1004878,7915010,CDM,272,RC,A7027,HCPCS,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
DISP OXYHOOD,7919113,CDM,270,RC,,,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
.........IPPB CIRCUIT 1560 HUDSON,7919301,CDM,270,RC,,,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
ENDOPATH REDUCER CAPS,7950165,CDM,270,RC,,,Outpatient,,,110,88,,93.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,99,90,,,percent of total billed charges,90% of total billed charges,38.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,75.57,68.7,,,percent of total billed charges,68.7% of total billed charges,88,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,63.8,58,,,percent of total billed charges,58% of total billed charges,22.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,22.41,99,
K-WIRE 1.4mm,1570045,CDM,278,RC,C1713,HCPCS,Both,,,115,92,,97.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,23.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,103.5,90,,,percent of total billed charges,90% of total billed charges,40.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,79.01,68.7,,,percent of total billed charges,68.7% of total billed charges,92,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,66.7,58,,,percent of total billed charges,58% of total billed charges,23.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,97.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,23.43,103.5,
AREDIA (PAMIDRONATE) 90MG INJ,2605010,CDM,250,RC,,,Outpatient,,,115,92,,97.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,23.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,103.5,90,,,percent of total billed charges,90% of total billed charges,40.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,79.01,68.7,,,percent of total billed charges,68.7% of total billed charges,92,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,66.7,58,,,percent of total billed charges,58% of total billed charges,23.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,97.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,23.43,103.5,
ZYPREXA (OLANZAPINE) INJ 10MG/ML,2605064,CDM,636,RC,,,Both,,,115,92,,97.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,23.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,103.5,90,,,percent of total billed charges,90% of total billed charges,40.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,79.01,68.7,,,percent of total billed charges,68.7% of total billed charges,92,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,66.7,58,,,percent of total billed charges,58% of total billed charges,23.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,97.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,23.43,103.5,
.GLUCOSE STRIP/BEDSIDE,3082948,CDM,301,RC,82948,HCPCS,Outpatient,,,115,92,,97.75,85,,,percent of total billed charges,85% of total billed charges,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,6.55,130,,,fee schedule,Pays 130% Medicare OPPS,4.8,120.37,,,fee schedule,120.37% of custom fee schedule,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.14,102,,,fee schedule,Pays 102% Medicare OPPS,103.5,90,,,percent of total billed charges,90% of total billed charges,4.99,125.18,,,fee schedule,125.18% of custom fee schedule,79.01,68.7,,,percent of total billed charges,68.7% of total billed charges,92,80,,,percent of total billed charges,80 percent of total billed charges,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,4.53,90,,,fee schedule,Pays 90% Medicare OPPS,66.7,58,,,percent of total billed charges,58% of total billed charges,4.8,120.37,,,fee schedule,120.37% of custom fee schedule,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,6.55,130,,,fee schedule,Pays 130% Medicare OPPS,97.75,85,,,percent of total billed charges,85% of total billed charges,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,4.53,103.5,
US GUIDE VASCULAR ACCESS,4676937,CDM,402,RC,76937,HCPCS,Outpatient,,,115,92,,97.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,23.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,64.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,103.5,90,,,percent of total billed charges,90% of total billed charges,40.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,79.01,68.7,,,percent of total billed charges,68.7% of total billed charges,92,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,66.7,58,,,percent of total billed charges,58% of total billed charges,23.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,97.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,23.43,103.5,
BIPAP FACE MASK MEDIUM 1004849,7900015,CDM,272,RC,A7027,HCPCS,Outpatient,,,115,92,,97.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,23.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,103.5,90,,,percent of total billed charges,90% of total billed charges,40.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,79.01,68.7,,,percent of total billed charges,68.7% of total billed charges,92,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,66.7,58,,,percent of total billed charges,58% of total billed charges,23.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,97.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,23.43,103.5,
BIPAP FACE MASK LARGE 1010871,7900016,CDM,272,RC,K0053,HCPCS,Outpatient,,,115,92,,97.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,23.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,103.5,90,,,percent of total billed charges,90% of total billed charges,40.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,79.01,68.7,,,percent of total billed charges,68.7% of total billed charges,92,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,66.7,58,,,percent of total billed charges,58% of total billed charges,23.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,97.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,23.43,103.5,
BIPAP CAP MASK LARGE 1061729,7900018,CDM,272,RC,A7027,HCPCS,Outpatient,,,115,92,,97.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,23.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,103.5,90,,,percent of total billed charges,90% of total billed charges,40.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,79.01,68.7,,,percent of total billed charges,68.7% of total billed charges,92,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,66.7,58,,,percent of total billed charges,58% of total billed charges,23.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,97.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,23.43,103.5,
BIPAP FACE MASK MEDIUM 73-1004849,7900020,CDM,272,RC,A7027,HCPCS,Outpatient,,,115,92,,97.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,23.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,103.5,90,,,percent of total billed charges,90% of total billed charges,40.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,79.01,68.7,,,percent of total billed charges,68.7% of total billed charges,92,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,66.7,58,,,percent of total billed charges,58% of total billed charges,23.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,97.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,23.43,103.5,
ABD BINDER 15 79-92149,7905279,CDM,270,RC,,,Outpatient,,,115,92,,97.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,23.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,64.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,103.5,90,,,percent of total billed charges,90% of total billed charges,40.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,79.01,68.7,,,percent of total billed charges,68.7% of total billed charges,92,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,66.7,58,,,percent of total billed charges,58% of total billed charges,23.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,97.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,23.43,103.5,
SUTURE 4-0 PLAIN 1604G,1570571,CDM,272,RC,,,Outpatient,,,120,96,,102,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,108,90,,,percent of total billed charges,90% of total billed charges,42,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,82.44,68.7,,,percent of total billed charges,68.7% of total billed charges,96,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,69.6,58,,,percent of total billed charges,58% of total billed charges,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,102,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,24.44,108,
SMOKE EVACUATION PENCIL NEPTUNE 000,1570805,CDM,272,RC,,,Outpatient,,,120,96,,102,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,108,90,,,percent of total billed charges,90% of total billed charges,42,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,82.44,68.7,,,percent of total billed charges,68.7% of total billed charges,96,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,69.6,58,,,percent of total billed charges,58% of total billed charges,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,102,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,24.44,108,
PRIMAXIN 250MG IV VIAL,2600017,CDM,636,RC,,,Both,,,120,96,,102,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,108,90,,,percent of total billed charges,90% of total billed charges,42,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,82.44,68.7,,,percent of total billed charges,68.7% of total billed charges,96,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,69.6,58,,,percent of total billed charges,58% of total billed charges,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,102,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,24.44,108,
LOTRISONE(CLOTRIMAZOLE/BETAMETHASONE)CRM,2600448,CDM,637,RC,,,Outpatient,,,120,96,,102,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,108,90,,,percent of total billed charges,90% of total billed charges,42,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,82.44,68.7,,,percent of total billed charges,68.7% of total billed charges,96,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,69.6,58,,,percent of total billed charges,58% of total billed charges,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,102,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,24.44,108,
SURE-CLOSE WOUND CLOSURE,2600553,CDM,270,RC,,,Outpatient,,,120,96,,102,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,108,90,,,percent of total billed charges,90% of total billed charges,42,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,82.44,68.7,,,percent of total billed charges,68.7% of total billed charges,96,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,69.6,58,,,percent of total billed charges,58% of total billed charges,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,102,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,24.44,108,
DURAGESIC (FENTANYL) PATCH 12MCG,2602266,CDM,637,RC,,,Outpatient,,,120,96,,102,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,108,90,,,percent of total billed charges,90% of total billed charges,42,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,82.44,68.7,,,percent of total billed charges,68.7% of total billed charges,96,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,69.6,58,,,percent of total billed charges,58% of total billed charges,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,102,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,24.44,108,
DURAGESIC (FENTANYL) PATCH 25MCG,2602267,CDM,637,RC,,,Outpatient,,,120,96,,102,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,108,90,,,percent of total billed charges,90% of total billed charges,42,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,82.44,68.7,,,percent of total billed charges,68.7% of total billed charges,96,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,69.6,58,,,percent of total billed charges,58% of total billed charges,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,102,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,24.44,108,
"DRUG SCREEN, REGULAR QUEST",3000092,CDM,301,RC,80377,HCPCS,Outpatient,,,120,96,,102,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,108,90,,,percent of total billed charges,90% of total billed charges,42,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,82.44,68.7,,,percent of total billed charges,68.7% of total billed charges,96,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,69.6,58,,,percent of total billed charges,58% of total billed charges,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,102,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,24.44,108,
CHROMIUM RBC LEVEL,3082495,CDM,301,RC,82495,HCPCS,Outpatient,,,120,96,,102,85,,,percent of total billed charges,85% of total billed charges,20.28,100,,,fee schedule,Pays 100% Medicare OPPS,20.28,100,,,fee schedule,Pays 100% Medicare OPPS,20.28,100,,,fee schedule,Pays 100% Medicare OPPS,26.36,130,,,fee schedule,Pays 130% Medicare OPPS,30.71,120.37,,,fee schedule,120.37% of custom fee schedule,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,20.68,102,,,fee schedule,Pays 102% Medicare OPPS,108,90,,,percent of total billed charges,90% of total billed charges,31.93,125.18,,,fee schedule,125.18% of custom fee schedule,82.44,68.7,,,percent of total billed charges,68.7% of total billed charges,96,80,,,percent of total billed charges,80 percent of total billed charges,20.28,100,,,fee schedule,Pays 100% Medicare OPPS,18.25,90,,,fee schedule,Pays 90% Medicare OPPS,69.6,58,,,percent of total billed charges,58% of total billed charges,30.71,120.37,,,fee schedule,120.37% of custom fee schedule,20.28,100,,,fee schedule,Pays 100% Medicare OPPS,26.36,130,,,fee schedule,Pays 130% Medicare OPPS,102,85,,,percent of total billed charges,85% of total billed charges,20.28,100,,,fee schedule,Pays 100% Medicare OPPS,18.25,108,
Blood test to measure the amount of iron that is in transit in the body,3083540,CDM,301,RC,83540,HCPCS,Outpatient,,,120,96,,102,85,,,percent of total billed charges,85% of total billed charges,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,8.41,130,,,fee schedule,Pays 130% Medicare OPPS,9.81,120.37,,,fee schedule,120.37% of custom fee schedule,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.59,102,,,fee schedule,Pays 102% Medicare OPPS,108,90,,,percent of total billed charges,90% of total billed charges,10.2,125.18,,,fee schedule,125.18% of custom fee schedule,82.44,68.7,,,percent of total billed charges,68.7% of total billed charges,96,80,,,percent of total billed charges,80 percent of total billed charges,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,5.82,90,,,fee schedule,Pays 90% Medicare OPPS,69.6,58,,,percent of total billed charges,58% of total billed charges,9.81,120.37,,,fee schedule,120.37% of custom fee schedule,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,8.41,130,,,fee schedule,Pays 130% Medicare OPPS,102,85,,,percent of total billed charges,85% of total billed charges,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,5.82,108,
REVERSE T3,3084482,CDM,301,RC,84482,HCPCS,Outpatient,,,120,96,,102,85,,,percent of total billed charges,85% of total billed charges,15.76,100,,,fee schedule,Pays 100% Medicare OPPS,15.76,100,,,fee schedule,Pays 100% Medicare OPPS,15.76,100,,,fee schedule,Pays 100% Medicare OPPS,20.48,130,,,fee schedule,Pays 130% Medicare OPPS,23.86,120.37,,,fee schedule,120.37% of custom fee schedule,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.07,102,,,fee schedule,Pays 102% Medicare OPPS,108,90,,,percent of total billed charges,90% of total billed charges,24.81,125.18,,,fee schedule,125.18% of custom fee schedule,82.44,68.7,,,percent of total billed charges,68.7% of total billed charges,96,80,,,percent of total billed charges,80 percent of total billed charges,15.76,100,,,fee schedule,Pays 100% Medicare OPPS,14.18,90,,,fee schedule,Pays 90% Medicare OPPS,69.6,58,,,percent of total billed charges,58% of total billed charges,23.86,120.37,,,fee schedule,120.37% of custom fee schedule,15.76,100,,,fee schedule,Pays 100% Medicare OPPS,20.48,130,,,fee schedule,Pays 130% Medicare OPPS,102,85,,,percent of total billed charges,85% of total billed charges,15.76,100,,,fee schedule,Pays 100% Medicare OPPS,14.18,108,
"Blood test, clotting time",3085610,CDM,305,RC,85610,HCPCS,Outpatient,,,120,96,,102,85,,,percent of total billed charges,85% of total billed charges,4.29,100,,,fee schedule,Pays 100% Medicare OPPS,4.29,100,,,fee schedule,Pays 100% Medicare OPPS,4.29,100,,,fee schedule,Pays 100% Medicare OPPS,5.57,130,,,fee schedule,Pays 130% Medicare OPPS,5.95,120.37,,,fee schedule,120.37% of custom fee schedule,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.37,102,,,fee schedule,Pays 102% Medicare OPPS,108,90,,,percent of total billed charges,90% of total billed charges,6.18,125.18,,,fee schedule,125.18% of custom fee schedule,82.44,68.7,,,percent of total billed charges,68.7% of total billed charges,96,80,,,percent of total billed charges,80 percent of total billed charges,4.29,100,,,fee schedule,Pays 100% Medicare OPPS,3.86,90,,,fee schedule,Pays 90% Medicare OPPS,69.6,58,,,percent of total billed charges,58% of total billed charges,5.95,120.37,,,fee schedule,120.37% of custom fee schedule,4.29,100,,,fee schedule,Pays 100% Medicare OPPS,5.57,130,,,fee schedule,Pays 130% Medicare OPPS,102,85,,,percent of total billed charges,85% of total billed charges,4.29,100,,,fee schedule,Pays 100% Medicare OPPS,3.86,108,
Use of water for therapy/exercises,5007113,CDM,420,RC,97113,HCPCS,Outpatient,,,120,96,,102,85,,,percent of total billed charges,85% of total billed charges,35.16,100,,,fee schedule,Pays 100% Medicare OPPS,35.16,100,,,fee schedule,Pays 100% Medicare OPPS,35.16,100,,,fee schedule,Pays 100% Medicare OPPS,45.27,130,,,fee schedule,Pays 130% Medicare OPPS,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,35.86,102,,,fee schedule,Pays 102% Medicare OPPS,108,90,,,percent of total billed charges,90% of total billed charges,42,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,82.44,68.7,,,percent of total billed charges,68.7% of total billed charges,96,80,,,percent of total billed charges,80 percent of total billed charges,35.16,100,,,fee schedule,Pays 100% Medicare OPPS,31.64,90,,,fee schedule,Pays 90% Medicare OPPS,69.6,58,,,percent of total billed charges,58% of total billed charges,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,34.82,100,,,fee schedule,Pays 100% Medicare OPPS,45.27,130,,,fee schedule,Pays 130% Medicare OPPS,102,85,,,percent of total billed charges,85% of total billed charges,35.16,100,,,fee schedule,Pays 100% Medicare OPPS,24.44,108,
PT MOD-PARAFFIN BATH (PER SESSION),5097018,CDM,420,RC,97018,HCPCS,Outpatient,,,120,96,,102,85,,,percent of total billed charges,85% of total billed charges,5.42,100,,,fee schedule,Pays 100% Medicare OPPS,5.42,100,,,fee schedule,Pays 100% Medicare OPPS,5.42,100,,,fee schedule,Pays 100% Medicare OPPS,6.97,130,,,fee schedule,Pays 130% Medicare OPPS,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.53,102,,,fee schedule,Pays 102% Medicare OPPS,108,90,,,percent of total billed charges,90% of total billed charges,42,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,82.44,68.7,,,percent of total billed charges,68.7% of total billed charges,96,80,,,percent of total billed charges,80 percent of total billed charges,5.42,100,,,fee schedule,Pays 100% Medicare OPPS,4.88,90,,,fee schedule,Pays 90% Medicare OPPS,69.6,58,,,percent of total billed charges,58% of total billed charges,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.36,100,,,fee schedule,Pays 100% Medicare OPPS,6.97,130,,,fee schedule,Pays 130% Medicare OPPS,102,85,,,percent of total billed charges,85% of total billed charges,5.42,100,,,fee schedule,Pays 100% Medicare OPPS,4.88,108,
Use of water for therapy/exercises,5097113,CDM,420,RC,97113,HCPCS,Outpatient,,,120,96,,102,85,,,percent of total billed charges,85% of total billed charges,35.16,100,,,fee schedule,Pays 100% Medicare OPPS,35.16,100,,,fee schedule,Pays 100% Medicare OPPS,35.16,100,,,fee schedule,Pays 100% Medicare OPPS,45.27,130,,,fee schedule,Pays 130% Medicare OPPS,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,35.86,102,,,fee schedule,Pays 102% Medicare OPPS,108,90,,,percent of total billed charges,90% of total billed charges,42,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,82.44,68.7,,,percent of total billed charges,68.7% of total billed charges,96,80,,,percent of total billed charges,80 percent of total billed charges,35.16,100,,,fee schedule,Pays 100% Medicare OPPS,31.64,90,,,fee schedule,Pays 90% Medicare OPPS,69.6,58,,,percent of total billed charges,58% of total billed charges,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,34.82,100,,,fee schedule,Pays 100% Medicare OPPS,45.27,130,,,fee schedule,Pays 130% Medicare OPPS,102,85,,,percent of total billed charges,85% of total billed charges,35.16,100,,,fee schedule,Pays 100% Medicare OPPS,24.44,108,
OT PARAFFIN BATH (PER SESSION),5197018,CDM,430,RC,97018,HCPCS,Outpatient,,,120,96,,102,85,,,percent of total billed charges,85% of total billed charges,5.42,100,,,fee schedule,Pays 100% Medicare OPPS,5.42,100,,,fee schedule,Pays 100% Medicare OPPS,5.42,100,,,fee schedule,Pays 100% Medicare OPPS,6.97,130,,,fee schedule,Pays 130% Medicare OPPS,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.53,102,,,fee schedule,Pays 102% Medicare OPPS,108,90,,,percent of total billed charges,90% of total billed charges,42,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,82.44,68.7,,,percent of total billed charges,68.7% of total billed charges,96,80,,,percent of total billed charges,80 percent of total billed charges,5.42,100,,,fee schedule,Pays 100% Medicare OPPS,4.88,90,,,fee schedule,Pays 90% Medicare OPPS,69.6,58,,,percent of total billed charges,58% of total billed charges,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5.36,100,,,fee schedule,Pays 100% Medicare OPPS,6.97,130,,,fee schedule,Pays 130% Medicare OPPS,102,85,,,percent of total billed charges,85% of total billed charges,5.42,100,,,fee schedule,Pays 100% Medicare OPPS,4.88,108,
Use of water for therapy/exercises,5197113,CDM,430,RC,97113,HCPCS,Outpatient,,,120,96,,102,85,,,percent of total billed charges,85% of total billed charges,35.16,100,,,fee schedule,Pays 100% Medicare OPPS,35.16,100,,,fee schedule,Pays 100% Medicare OPPS,35.16,100,,,fee schedule,Pays 100% Medicare OPPS,45.27,130,,,fee schedule,Pays 130% Medicare OPPS,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,35.86,102,,,fee schedule,Pays 102% Medicare OPPS,108,90,,,percent of total billed charges,90% of total billed charges,42,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,82.44,68.7,,,percent of total billed charges,68.7% of total billed charges,96,80,,,percent of total billed charges,80 percent of total billed charges,35.16,100,,,fee schedule,Pays 100% Medicare OPPS,31.64,90,,,fee schedule,Pays 90% Medicare OPPS,69.6,58,,,percent of total billed charges,58% of total billed charges,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,34.82,100,,,fee schedule,Pays 100% Medicare OPPS,45.27,130,,,fee schedule,Pays 130% Medicare OPPS,102,85,,,percent of total billed charges,85% of total billed charges,35.16,100,,,fee schedule,Pays 100% Medicare OPPS,24.44,108,
CATH 3-WAY,7905201,CDM,270,RC,,,Outpatient,,,120,96,,102,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,108,90,,,percent of total billed charges,90% of total billed charges,42,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,82.44,68.7,,,percent of total billed charges,68.7% of total billed charges,96,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,69.6,58,,,percent of total billed charges,58% of total billed charges,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,102,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,24.44,108,
PARA-BLOC TRAY,7905296,CDM,270,RC,,,Outpatient,,,120,96,,102,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,108,90,,,percent of total billed charges,90% of total billed charges,42,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,82.44,68.7,,,percent of total billed charges,68.7% of total billed charges,96,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,69.6,58,,,percent of total billed charges,58% of total billed charges,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,102,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,24.44,108,
TUBE EAR SHEEHY VENTILATION,7905768,CDM,270,RC,,,Outpatient,,,120,96,,102,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,108,90,,,percent of total billed charges,90% of total billed charges,42,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,82.44,68.7,,,percent of total billed charges,68.7% of total billed charges,96,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,69.6,58,,,percent of total billed charges,58% of total billed charges,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,102,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,24.44,108,
TUBE EAR RUBE VENTILATION,7905773,CDM,270,RC,,,Outpatient,,,120,96,,102,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,108,90,,,percent of total billed charges,90% of total billed charges,42,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,82.44,68.7,,,percent of total billed charges,68.7% of total billed charges,96,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,69.6,58,,,percent of total billed charges,58% of total billed charges,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,102,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,24.44,108,
DRESSING KALTOSTAT 168117,7905944,CDM,270,RC,,,Outpatient,,,120,96,,102,85,,,percent of total billed charges,85% of total billed charges,30,100,,,fee schedule,Pays 100% Medicare OPPS,30,100,,,fee schedule,Pays 100% Medicare OPPS,30,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,108,90,,,percent of total billed charges,90% of total billed charges,42,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,82.44,68.7,,,percent of total billed charges,68.7% of total billed charges,96,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,108,90,,,fee schedule,Pays 90% Medicare OPPS,69.6,58,,,percent of total billed charges,58% of total billed charges,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,102,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,24.44,108,
DEFIB ELECTRODES 31319281,7950117,CDM,270,RC,,,Outpatient,,,120,96,,102,85,,,percent of total billed charges,85% of total billed charges,30,100,,,fee schedule,Pays 100% Medicare OPPS,30,100,,,fee schedule,Pays 100% Medicare OPPS,30,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,108,90,,,percent of total billed charges,90% of total billed charges,42,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,82.44,68.7,,,percent of total billed charges,68.7% of total billed charges,96,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,108,90,,,fee schedule,Pays 90% Medicare OPPS,69.6,58,,,percent of total billed charges,58% of total billed charges,24.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,102,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,24.44,108,
OCUFLOX (OFLOXACIN) 0.3% OPTH DROPS 10ML,2600026,CDM,250,RC,,,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,31.25,100,,,fee schedule,Pays 100% Medicare OPPS,31.25,100,,,fee schedule,Pays 100% Medicare OPPS,31.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,112.5,90,,,percent of total billed charges,90% of total billed charges,43.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,112.5,90,,,fee schedule,Pays 90% Medicare OPPS,72.5,58,,,percent of total billed charges,58% of total billed charges,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,106.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,25.46,112.5,
ETHYL CHLORIDE SPRAY 3.5FL OZ.,2600154,CDM,270,RC,,,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,31.25,100,,,fee schedule,Pays 100% Medicare OPPS,31.25,100,,,fee schedule,Pays 100% Medicare OPPS,31.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,112.5,90,,,percent of total billed charges,90% of total billed charges,43.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,112.5,90,,,fee schedule,Pays 90% Medicare OPPS,72.5,58,,,percent of total billed charges,58% of total billed charges,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,106.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,25.46,112.5,
CATAPRES-TTS-1 (CLONIDINE TTS-1) PATCH,2602224,CDM,637,RC,,,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,31.25,100,,,fee schedule,Pays 100% Medicare OPPS,31.25,100,,,fee schedule,Pays 100% Medicare OPPS,31.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,112.5,90,,,percent of total billed charges,90% of total billed charges,43.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,112.5,90,,,fee schedule,Pays 90% Medicare OPPS,72.5,58,,,percent of total billed charges,58% of total billed charges,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,106.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,25.46,112.5,
NYSTATIN POWDER 15GM TOPICAL,2602276,CDM,637,RC,,,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,31.25,100,,,fee schedule,Pays 100% Medicare OPPS,31.25,100,,,fee schedule,Pays 100% Medicare OPPS,31.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,112.5,90,,,percent of total billed charges,90% of total billed charges,43.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,112.5,90,,,fee schedule,Pays 90% Medicare OPPS,72.5,58,,,percent of total billed charges,58% of total billed charges,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,106.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,25.46,112.5,
ADMIN 1ST PFIZER DOSE COVID19 VACCINE,2611113,CDM,771,RC,0001A,HCPCS,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,35.88,102,,,fee schedule,Pays 102% Medicare OPPS,112.5,90,,,percent of total billed charges,90% of total billed charges,43.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,31.66,90,,,fee schedule,Pays 90% Medicare OPPS,72.5,58,,,percent of total billed charges,58% of total billed charges,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,25.46,112.5,
ADMIN 3RD MODERNA DOSE COVID19 VACCINE,2611115,CDM,771,RC,0013A,HCPCS,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,35.88,102,,,fee schedule,Pays 102% Medicare OPPS,112.5,90,,,percent of total billed charges,90% of total billed charges,43.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,31.66,90,,,fee schedule,Pays 90% Medicare OPPS,72.5,58,,,percent of total billed charges,58% of total billed charges,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,25.46,112.5,
Chemical test of the blood to measure presence or concentration of a substance in the blood,3000125,CDM,301,RC,83516,HCPCS,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.76,102,,,fee schedule,Pays 102% Medicare OPPS,112.5,90,,,percent of total billed charges,90% of total billed charges,16.84,125.18,,,fee schedule,125.18% of custom fee schedule,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,90,,,fee schedule,Pays 90% Medicare OPPS,72.5,58,,,percent of total billed charges,58% of total billed charges,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,106.25,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,112.5,
.RICKETTSIAL IgG,3000262,CDM,300,RC,86255,HCPCS,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,,,fee schedule,Pays 130% Medicare OPPS,18.25,120.37,,,fee schedule,120.37% of custom fee schedule,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.29,102,,,fee schedule,Pays 102% Medicare OPPS,112.5,90,,,percent of total billed charges,90% of total billed charges,18.98,125.18,,,fee schedule,125.18% of custom fee schedule,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,10.84,90,,,fee schedule,Pays 90% Medicare OPPS,72.5,58,,,percent of total billed charges,58% of total billed charges,18.25,120.37,,,fee schedule,120.37% of custom fee schedule,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,,,fee schedule,Pays 130% Medicare OPPS,106.25,85,,,percent of total billed charges,85% of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,10.84,112.5,
3RD ACR BINDING AUTOANTIBODY,3000600,CDM,300,RC,83519,HCPCS,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,23.92,130,,,fee schedule,Pays 130% Medicare OPPS,20.45,120.37,,,fee schedule,120.37% of custom fee schedule,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.76,102,,,fee schedule,Pays 102% Medicare OPPS,112.5,90,,,percent of total billed charges,90% of total billed charges,21.27,125.18,,,fee schedule,125.18% of custom fee schedule,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.55,90,,,fee schedule,Pays 90% Medicare OPPS,72.5,58,,,percent of total billed charges,58% of total billed charges,20.45,120.37,,,fee schedule,120.37% of custom fee schedule,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,23.92,130,,,fee schedule,Pays 130% Medicare OPPS,106.25,85,,,percent of total billed charges,85% of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.55,112.5,
AUTOANTIBODIES TOTAL,3000601,CDM,300,RC,86255,HCPCS,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,,,fee schedule,Pays 130% Medicare OPPS,18.25,120.37,,,fee schedule,120.37% of custom fee schedule,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.29,102,,,fee schedule,Pays 102% Medicare OPPS,112.5,90,,,percent of total billed charges,90% of total billed charges,18.98,125.18,,,fee schedule,125.18% of custom fee schedule,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,10.84,90,,,fee schedule,Pays 90% Medicare OPPS,72.5,58,,,percent of total billed charges,58% of total billed charges,18.25,120.37,,,fee schedule,120.37% of custom fee schedule,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,,,fee schedule,Pays 130% Medicare OPPS,106.25,85,,,percent of total billed charges,85% of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,10.84,112.5,
.B2 IGG,3000655,CDM,300,RC,86146,HCPCS,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,25.45,100,,,fee schedule,Pays 100% Medicare OPPS,25.45,100,,,fee schedule,Pays 100% Medicare OPPS,25.45,100,,,fee schedule,Pays 100% Medicare OPPS,33.08,130,,,fee schedule,Pays 130% Medicare OPPS,38.51,120.37,,,fee schedule,120.37% of custom fee schedule,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.95,102,,,fee schedule,Pays 102% Medicare OPPS,112.5,90,,,percent of total billed charges,90% of total billed charges,40.05,125.18,,,fee schedule,125.18% of custom fee schedule,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,25.45,100,,,fee schedule,Pays 100% Medicare OPPS,22.9,90,,,fee schedule,Pays 90% Medicare OPPS,72.5,58,,,percent of total billed charges,58% of total billed charges,38.51,120.37,,,fee schedule,120.37% of custom fee schedule,25.45,100,,,fee schedule,Pays 100% Medicare OPPS,33.08,130,,,fee schedule,Pays 130% Medicare OPPS,106.25,85,,,percent of total billed charges,85% of total billed charges,25.45,100,,,fee schedule,Pays 100% Medicare OPPS,22.9,112.5,
.B2 IGM,3000656,CDM,300,RC,86146,HCPCS,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,25.45,100,,,fee schedule,Pays 100% Medicare OPPS,25.45,100,,,fee schedule,Pays 100% Medicare OPPS,25.45,100,,,fee schedule,Pays 100% Medicare OPPS,33.08,130,,,fee schedule,Pays 130% Medicare OPPS,38.51,120.37,,,fee schedule,120.37% of custom fee schedule,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.95,102,,,fee schedule,Pays 102% Medicare OPPS,112.5,90,,,percent of total billed charges,90% of total billed charges,40.05,125.18,,,fee schedule,125.18% of custom fee schedule,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,25.45,100,,,fee schedule,Pays 100% Medicare OPPS,22.9,90,,,fee schedule,Pays 90% Medicare OPPS,72.5,58,,,percent of total billed charges,58% of total billed charges,38.51,120.37,,,fee schedule,120.37% of custom fee schedule,25.45,100,,,fee schedule,Pays 100% Medicare OPPS,33.08,130,,,fee schedule,Pays 130% Medicare OPPS,106.25,85,,,percent of total billed charges,85% of total billed charges,25.45,100,,,fee schedule,Pays 100% Medicare OPPS,22.9,112.5,
.B2 IGA,3000657,CDM,300,RC,86146,HCPCS,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,25.45,100,,,fee schedule,Pays 100% Medicare OPPS,25.45,100,,,fee schedule,Pays 100% Medicare OPPS,25.45,100,,,fee schedule,Pays 100% Medicare OPPS,33.08,130,,,fee schedule,Pays 130% Medicare OPPS,38.51,120.37,,,fee schedule,120.37% of custom fee schedule,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.95,102,,,fee schedule,Pays 102% Medicare OPPS,112.5,90,,,percent of total billed charges,90% of total billed charges,40.05,125.18,,,fee schedule,125.18% of custom fee schedule,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,25.45,100,,,fee schedule,Pays 100% Medicare OPPS,22.9,90,,,fee schedule,Pays 90% Medicare OPPS,72.5,58,,,percent of total billed charges,58% of total billed charges,38.51,120.37,,,fee schedule,120.37% of custom fee schedule,25.45,100,,,fee schedule,Pays 100% Medicare OPPS,33.08,130,,,fee schedule,Pays 130% Medicare OPPS,106.25,85,,,percent of total billed charges,85% of total billed charges,25.45,100,,,fee schedule,Pays 100% Medicare OPPS,22.9,112.5,
Chemical test of the blood to measure presence or concentration of a substance in the blood,3000659,CDM,301,RC,83516,HCPCS,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.76,102,,,fee schedule,Pays 102% Medicare OPPS,112.5,90,,,percent of total billed charges,90% of total billed charges,16.84,125.18,,,fee schedule,125.18% of custom fee schedule,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,90,,,fee schedule,Pays 90% Medicare OPPS,72.5,58,,,percent of total billed charges,58% of total billed charges,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,106.25,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,112.5,
Chemical test of the blood to measure presence or concentration of a substance in the blood,3000660,CDM,301,RC,83516,HCPCS,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.76,102,,,fee schedule,Pays 102% Medicare OPPS,112.5,90,,,percent of total billed charges,90% of total billed charges,16.84,125.18,,,fee schedule,125.18% of custom fee schedule,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,90,,,fee schedule,Pays 90% Medicare OPPS,72.5,58,,,percent of total billed charges,58% of total billed charges,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,106.25,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,112.5,
.ENDOMYSIAL IGA,3000670,CDM,301,RC,86255,HCPCS,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,,,fee schedule,Pays 130% Medicare OPPS,18.25,120.37,,,fee schedule,120.37% of custom fee schedule,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.29,102,,,fee schedule,Pays 102% Medicare OPPS,112.5,90,,,percent of total billed charges,90% of total billed charges,18.98,125.18,,,fee schedule,125.18% of custom fee schedule,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,10.84,90,,,fee schedule,Pays 90% Medicare OPPS,72.5,58,,,percent of total billed charges,58% of total billed charges,18.25,120.37,,,fee schedule,120.37% of custom fee schedule,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,,,fee schedule,Pays 130% Medicare OPPS,106.25,85,,,percent of total billed charges,85% of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,10.84,112.5,
DRUG SCREEN EMH CONTRACT,3000710,CDM,301,RC,80377,HCPCS,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,112.5,90,,,percent of total billed charges,90% of total billed charges,43.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,72.5,58,,,percent of total billed charges,58% of total billed charges,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,106.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,25.46,112.5,
Blood test to measure a type of thyroid hormone,3000805,CDM,301,RC,84436,HCPCS,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,6.87,100,,,fee schedule,Pays 100% Medicare OPPS,6.87,100,,,fee schedule,Pays 100% Medicare OPPS,6.87,100,,,fee schedule,Pays 100% Medicare OPPS,8.93,130,,,fee schedule,Pays 130% Medicare OPPS,10.41,120.37,,,fee schedule,120.37% of custom fee schedule,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,7,102,,,fee schedule,Pays 102% Medicare OPPS,112.5,90,,,percent of total billed charges,90% of total billed charges,10.83,125.18,,,fee schedule,125.18% of custom fee schedule,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,6.87,100,,,fee schedule,Pays 100% Medicare OPPS,6.18,90,,,fee schedule,Pays 90% Medicare OPPS,72.5,58,,,percent of total billed charges,58% of total billed charges,10.41,120.37,,,fee schedule,120.37% of custom fee schedule,6.87,100,,,fee schedule,Pays 100% Medicare OPPS,8.93,130,,,fee schedule,Pays 130% Medicare OPPS,106.25,85,,,percent of total billed charges,85% of total billed charges,6.87,100,,,fee schedule,Pays 100% Medicare OPPS,6.18,112.5,
CALPROTECTIN STOOL,3000900,CDM,300,RC,83993,HCPCS,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,19.63,100,,,fee schedule,Pays 100% Medicare OPPS,19.63,100,,,fee schedule,Pays 100% Medicare OPPS,19.63,100,,,fee schedule,Pays 100% Medicare OPPS,25.51,130,,,fee schedule,Pays 130% Medicare OPPS,29.71,120.37,,,fee schedule,120.37% of custom fee schedule,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,20.02,102,,,fee schedule,Pays 102% Medicare OPPS,112.5,90,,,percent of total billed charges,90% of total billed charges,30.89,125.18,,,fee schedule,125.18% of custom fee schedule,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,19.63,100,,,fee schedule,Pays 100% Medicare OPPS,17.66,90,,,fee schedule,Pays 90% Medicare OPPS,72.5,58,,,percent of total billed charges,58% of total billed charges,29.71,120.37,,,fee schedule,120.37% of custom fee schedule,19.63,100,,,fee schedule,Pays 100% Medicare OPPS,25.51,130,,,fee schedule,Pays 130% Medicare OPPS,106.25,85,,,percent of total billed charges,85% of total billed charges,19.63,100,,,fee schedule,Pays 100% Medicare OPPS,17.66,112.5,
Blood test to measure a type of thyroid hormone,3084436,CDM,301,RC,84436,HCPCS,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,6.87,100,,,fee schedule,Pays 100% Medicare OPPS,6.87,100,,,fee schedule,Pays 100% Medicare OPPS,6.87,100,,,fee schedule,Pays 100% Medicare OPPS,8.93,130,,,fee schedule,Pays 130% Medicare OPPS,10.41,120.37,,,fee schedule,120.37% of custom fee schedule,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,7,102,,,fee schedule,Pays 102% Medicare OPPS,112.5,90,,,percent of total billed charges,90% of total billed charges,10.83,125.18,,,fee schedule,125.18% of custom fee schedule,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,6.87,100,,,fee schedule,Pays 100% Medicare OPPS,6.18,90,,,fee schedule,Pays 90% Medicare OPPS,72.5,58,,,percent of total billed charges,58% of total billed charges,10.41,120.37,,,fee schedule,120.37% of custom fee schedule,6.87,100,,,fee schedule,Pays 100% Medicare OPPS,8.93,130,,,fee schedule,Pays 130% Medicare OPPS,106.25,85,,,percent of total billed charges,85% of total billed charges,6.87,100,,,fee schedule,Pays 100% Medicare OPPS,6.18,112.5,
RC DIFFERENTIAL/AUTO ADS OF SERUM,3086978,CDM,300,RC,86978,HCPCS,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,38.83,130,,,fee schedule,Pays 130% Medicare OPPS,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.01,102,,,fee schedule,Pays 102% Medicare OPPS,112.5,90,,,percent of total billed charges,90% of total billed charges,43.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,27.36,90,,,fee schedule,Pays 90% Medicare OPPS,72.5,58,,,percent of total billed charges,58% of total billed charges,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,29.87,100,,,fee schedule,Pays 100% Medicare OPPS,38.83,130,,,fee schedule,Pays 130% Medicare OPPS,106.25,85,,,percent of total billed charges,85% of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,25.46,112.5,
A test used to determine which medications work on bacteria for fungi,3087184,CDM,306,RC,87186,HCPCS,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,8.65,100,,,fee schedule,Pays 100% Medicare OPPS,8.65,100,,,fee schedule,Pays 100% Medicare OPPS,8.65,100,,,fee schedule,Pays 100% Medicare OPPS,11.24,130,,,fee schedule,Pays 130% Medicare OPPS,13.08,120.37,,,fee schedule,120.37% of custom fee schedule,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.82,102,,,fee schedule,Pays 102% Medicare OPPS,112.5,90,,,percent of total billed charges,90% of total billed charges,13.61,125.18,,,fee schedule,125.18% of custom fee schedule,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,8.65,100,,,fee schedule,Pays 100% Medicare OPPS,7.78,90,,,fee schedule,Pays 90% Medicare OPPS,72.5,58,,,percent of total billed charges,58% of total billed charges,13.08,120.37,,,fee schedule,120.37% of custom fee schedule,8.65,100,,,fee schedule,Pays 100% Medicare OPPS,11.24,130,,,fee schedule,Pays 130% Medicare OPPS,106.25,85,,,percent of total billed charges,85% of total billed charges,8.65,100,,,fee schedule,Pays 100% Medicare OPPS,7.78,112.5,
Automated urinalysis test,3099006,CDM,300,RC,81003,HCPCS,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,2.25,100,,,fee schedule,Pays 100% Medicare OPPS,2.25,100,,,fee schedule,Pays 100% Medicare OPPS,2.25,100,,,fee schedule,Pays 100% Medicare OPPS,2.92,130,,,fee schedule,Pays 130% Medicare OPPS,3.41,120.37,,,fee schedule,120.37% of custom fee schedule,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2.29,102,,,fee schedule,Pays 102% Medicare OPPS,112.5,90,,,percent of total billed charges,90% of total billed charges,3.54,125.18,,,fee schedule,125.18% of custom fee schedule,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,2.25,100,,,fee schedule,Pays 100% Medicare OPPS,2.02,90,,,fee schedule,Pays 90% Medicare OPPS,72.5,58,,,percent of total billed charges,58% of total billed charges,3.41,120.37,,,fee schedule,120.37% of custom fee schedule,2.25,100,,,fee schedule,Pays 100% Medicare OPPS,2.92,130,,,fee schedule,Pays 130% Medicare OPPS,106.25,85,,,percent of total billed charges,85% of total billed charges,2.25,100,,,fee schedule,Pays 100% Medicare OPPS,2.02,112.5,
ANKLE/FOOT ORTHOSIS 7839-01,5007130,CDM,274,RC,L1930,HCPCS,Both,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,112.5,90,,,percent of total billed charges,90% of total billed charges,43.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,72.5,58,,,percent of total billed charges,58% of total billed charges,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,106.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,25.46,112.5,
..........IPPB TREATMENT,5500004,CDM,410,RC,94640,HCPCS,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,172.23,102,,,fee schedule,Pays 102% Medicare OPPS,112.5,90,,,percent of total billed charges,90% of total billed charges,43.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,151.96,90,,,fee schedule,Pays 90% Medicare OPPS,72.5,58,,,percent of total billed charges,58% of total billed charges,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,168.43,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,106.25,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,25.46,218.97,
CPT (CHEST PHYSIO THER INITIAL),5594667,CDM,410,RC,94667,HCPCS,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,112.5,90,,,percent of total billed charges,90% of total billed charges,43.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,72.5,58,,,percent of total billed charges,58% of total billed charges,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,106.25,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,25.46,132.76,
SPLINT ELBOW TENNIS,7905758,CDM,270,RC,,,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,112.5,90,,,percent of total billed charges,90% of total billed charges,43.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,72.5,58,,,percent of total billed charges,58% of total billed charges,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,106.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,25.46,112.5,
DURAPREP SOLUTION,7905808,CDM,270,RC,,,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,112.5,90,,,percent of total billed charges,90% of total billed charges,43.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,72.5,58,,,percent of total billed charges,58% of total billed charges,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,106.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,25.46,112.5,
CATH COUDE 14 FR.,7905941,CDM,270,RC,,,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,112.5,90,,,percent of total billed charges,90% of total billed charges,43.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,72.5,58,,,percent of total billed charges,58% of total billed charges,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,106.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,25.46,112.5,
***DO NOT USE***,7905986,CDM,270,RC,,,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,112.5,90,,,percent of total billed charges,90% of total billed charges,43.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,72.5,58,,,percent of total billed charges,58% of total billed charges,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,106.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,25.46,112.5,
CHEST TRAY,7905993,CDM,270,RC,,,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,112.5,90,,,percent of total billed charges,90% of total billed charges,43.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,72.5,58,,,percent of total billed charges,58% of total billed charges,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,106.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,25.46,112.5,
...........MDI SPACER,7915425,CDM,270,RC,,,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,112.5,90,,,percent of total billed charges,90% of total billed charges,43.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,72.5,58,,,percent of total billed charges,58% of total billed charges,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,106.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,25.46,112.5,
ELECTRODE PEDIATRIC 224850,7950089,CDM,270,RC,,,Outpatient,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,70.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,112.5,90,,,percent of total billed charges,90% of total billed charges,43.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,72.5,58,,,percent of total billed charges,58% of total billed charges,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,106.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,25.46,112.5,
NEEDLE SCLERotherAPY M00518361,7950188,CDM,278,RC,,,Both,,,125,100,,106.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,112.5,90,,,percent of total billed charges,90% of total billed charges,43.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,85.88,68.7,,,percent of total billed charges,68.7% of total billed charges,100,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,72.5,58,,,percent of total billed charges,58% of total billed charges,25.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,106.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,25.46,112.5,
SMOKE EVACUATION PENCIL NEPTUNE 004,1570807,CDM,272,RC,,,Outpatient,,,130,104,,110.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,26.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,73.45,56.5,,,percent of total billed charges,56.5 percent of total billed charges,73.45,56.5,,,percent of total billed charges,56.5 percent of total billed charges,73.45,56.5,,,percent of total billed charges,56.5 percent of total billed charges,73.45,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,117,90,,,percent of total billed charges,90% of total billed charges,45.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,89.31,68.7,,,percent of total billed charges,68.7% of total billed charges,104,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,75.4,58,,,percent of total billed charges,58% of total billed charges,26.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,110.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,26.48,117,
**DO NOT USE**,7950040,CDM,272,RC,,,Outpatient,,,130,104,,110.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,26.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,73.45,56.5,,,percent of total billed charges,56.5 percent of total billed charges,73.45,56.5,,,percent of total billed charges,56.5 percent of total billed charges,73.45,56.5,,,percent of total billed charges,56.5 percent of total billed charges,73.45,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,117,90,,,percent of total billed charges,90% of total billed charges,45.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,89.31,68.7,,,percent of total billed charges,68.7% of total billed charges,104,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,75.4,58,,,percent of total billed charges,58% of total billed charges,26.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,110.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,26.48,117,
LIGATION CLIP POLY NON ABSORB 544240,7950110,CDM,272,RC,,,Outpatient,,,130,104,,110.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,26.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,73.45,56.5,,,percent of total billed charges,56.5 percent of total billed charges,73.45,56.5,,,percent of total billed charges,56.5 percent of total billed charges,73.45,56.5,,,percent of total billed charges,56.5 percent of total billed charges,73.45,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,117,90,,,percent of total billed charges,90% of total billed charges,45.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,89.31,68.7,,,percent of total billed charges,68.7% of total billed charges,104,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,75.4,58,,,percent of total billed charges,58% of total billed charges,26.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,110.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,26.48,117,
LIGATION CLIP POLYMER NON ABSORBABLE,7950113,CDM,272,RC,,,Outpatient,,,130,104,,110.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,26.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,73.45,56.5,,,percent of total billed charges,56.5 percent of total billed charges,73.45,56.5,,,percent of total billed charges,56.5 percent of total billed charges,73.45,56.5,,,percent of total billed charges,56.5 percent of total billed charges,73.45,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,117,90,,,percent of total billed charges,90% of total billed charges,45.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,89.31,68.7,,,percent of total billed charges,68.7% of total billed charges,104,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,75.4,58,,,percent of total billed charges,58% of total billed charges,26.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,110.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,26.48,117,
HERNIA BARD MESH 1 X 4,7950213,CDM,278,RC,C1781,HCPCS,Both,,,130,104,,110.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,26.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,117,90,,,percent of total billed charges,90% of total billed charges,45.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,89.31,68.7,,,percent of total billed charges,68.7% of total billed charges,104,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,75.4,58,,,percent of total billed charges,58% of total billed charges,26.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,110.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,26.48,117,
IV CONCURRENT INFUSION,1096368,CDM,450,RC,96368,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
K-WIRE 1.1 TROCAR 100MM,1570357,CDM,278,RC,C1713,HCPCS,Both,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
SUTURE 1 CHROMIC 3813G,1570517,CDM,272,RC,,,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
SUTURE 4-0 PROLENE 8699G,1570573,CDM,272,RC,,,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
TRIAGE,2000001,CDM,450,RC,99281,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,65.16,100,,,fee schedule,Pays 100% Medicare OPPS,65.16,100,,,fee schedule,Pays 100% Medicare OPPS,65.16,100,,,fee schedule,Pays 100% Medicare OPPS,85.85,130,,,fee schedule,Pays 130% Medicare OPPS,50,100,,,case rate,"ER level 1, Revenue Code 450 per visit $50.00",135,100,,,percent of total billed charges,671 dollar flat fee for ER,135,100,,,percent of total billed charges,671 dollar flat fee for ER,135,100,,,percent of total billed charges,671 dollar flat fee for ER,135,100,,,percent of total billed charges,671 dollar flat fee for ER,66.45,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,65.16,100,,,fee schedule,Pays 100% Medicare OPPS,58.64,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,66.04,100,,,fee schedule,Pays 100% Medicare OPPS,85.85,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,65.16,100,,,fee schedule,Pays 100% Medicare OPPS,27.5,135,
IV CONCURRENT INFUSION,2096368,CDM,450,RC,96368,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
NULYTELY (PGE-3350 + LYTES) 4000ML,2600044,CDM,250,RC,,,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
ROCEPHIN INJ (CEFTRIAXONE NA) 250MG,2600051,CDM,636,RC,J0696,HCPCS,Both,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,0.6,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,0.63,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,0.6,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.6,121.5,
GARAMYCIN (GENTAMICIN SULF) OPHTH OINT,2601022,CDM,637,RC,,,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
ZOVIRAX (ACYCLOVIR) INJ 500MG,2601050,CDM,636,RC,J0133,HCPCS,Both,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,0.07,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,0.08,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,0.07,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.07,121.5,
MORPHINE PCA 1MG/1ML INJ,2601202,CDM,636,RC,J2270,HCPCS,Both,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.57,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,3.72,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,3.57,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.57,121.5,
NF-MIVACRON (MIVACURIUM) 20MG/10ML VIAL,2601360,CDM,636,RC,,,Both,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
SOLU-MEDROL (METHYLPREDNIS) INJ 1000MG,2601409,CDM,636,RC,,,Both,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
APRESOLINE (HYDRALAZINE HCL) INJ 20MG,2602515,CDM,636,RC,J0360,HCPCS,Both,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,8.32,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,8,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8,121.5,
ACTIDOSE (CHARCOAL AQUEOUS) 50GM/240ML,2603000,CDM,637,RC,,,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
ADMIN 1ST PFIZER PEDIATRIC COVID19 VAC,2611116,CDM,771,RC,0071A,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,35.88,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,31.66,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,27.5,121.5,
CELL CO BODY FLUID WO DIF,3000041,CDM,309,RC,89050,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,6.13,130,,,fee schedule,Pays 130% Medicare OPPS,7.16,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.81,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,7.45,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.24,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.16,120.37,,,fee schedule,120.37% of custom fee schedule,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,6.13,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.24,121.5,
CELL COUNT CSF,3000042,CDM,300,RC,89050,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,6.13,130,,,fee schedule,Pays 130% Medicare OPPS,7.16,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.81,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,7.45,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.24,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.16,120.37,,,fee schedule,120.37% of custom fee schedule,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,6.13,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.24,121.5,
CELL COUNT PERITINEAL,3000043,CDM,309,RC,89050,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,6.13,130,,,fee schedule,Pays 130% Medicare OPPS,7.16,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.81,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,7.45,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.24,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.16,120.37,,,fee schedule,120.37% of custom fee schedule,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,6.13,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.24,121.5,
Blood test to identify bacteria that may be contributing to symptoms in the gastrointestinal tract,3000072,CDM,306,RC,87046,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,12.27,130,,,fee schedule,Pays 130% Medicare OPPS,3.57,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.62,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,3.72,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,8.49,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,3.57,120.37,,,fee schedule,120.37% of custom fee schedule,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,12.27,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,3.57,121.5,
Blood test to identify bacteria that may be contributing to symptoms in the gastrointestinal tract,3000078,CDM,306,RC,87046,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,12.27,130,,,fee schedule,Pays 130% Medicare OPPS,3.57,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.62,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,3.72,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,8.49,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,3.57,120.37,,,fee schedule,120.37% of custom fee schedule,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,12.27,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,3.57,121.5,
.FUNGUS STAIN,3000117,CDM,306,RC,87206,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.39,100,,,fee schedule,Pays 100% Medicare OPPS,5.39,100,,,fee schedule,Pays 100% Medicare OPPS,5.39,100,,,fee schedule,Pays 100% Medicare OPPS,7,130,,,fee schedule,Pays 130% Medicare OPPS,8.12,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.49,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.45,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.39,100,,,fee schedule,Pays 100% Medicare OPPS,4.85,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,8.12,120.37,,,fee schedule,120.37% of custom fee schedule,5.39,100,,,fee schedule,Pays 100% Medicare OPPS,7,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.39,100,,,fee schedule,Pays 100% Medicare OPPS,4.85,121.5,
.INFLUENZA B RAPID TEST,3000172,CDM,300,RC,87400,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,14.13,100,,,fee schedule,Pays 100% Medicare OPPS,14.13,100,,,fee schedule,Pays 100% Medicare OPPS,14.13,100,,,fee schedule,Pays 100% Medicare OPPS,18.36,130,,,fee schedule,Pays 130% Medicare OPPS,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.41,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,18.88,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,14.13,100,,,fee schedule,Pays 100% Medicare OPPS,12.71,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,14.13,100,,,fee schedule,Pays 100% Medicare OPPS,18.36,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,14.13,100,,,fee schedule,Pays 100% Medicare OPPS,12.71,121.5,
3RD MALARIA SMEAR,3000191,CDM,306,RC,87207,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.99,100,,,fee schedule,Pays 100% Medicare OPPS,5.99,100,,,fee schedule,Pays 100% Medicare OPPS,5.99,100,,,fee schedule,Pays 100% Medicare OPPS,7.78,130,,,fee schedule,Pays 130% Medicare OPPS,9.06,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.1,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,9.43,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.99,100,,,fee schedule,Pays 100% Medicare OPPS,5.39,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,9.06,120.37,,,fee schedule,120.37% of custom fee schedule,5.99,100,,,fee schedule,Pays 100% Medicare OPPS,7.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.99,100,,,fee schedule,Pays 100% Medicare OPPS,5.39,121.5,
PH BODY FLUID LEVEL,3000204,CDM,301,RC,83986,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,3.58,100,,,fee schedule,Pays 100% Medicare OPPS,3.58,100,,,fee schedule,Pays 100% Medicare OPPS,3.58,100,,,fee schedule,Pays 100% Medicare OPPS,4.65,130,,,fee schedule,Pays 130% Medicare OPPS,5.42,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3.65,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,5.63,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,3.58,100,,,fee schedule,Pays 100% Medicare OPPS,3.22,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,5.42,120.37,,,fee schedule,120.37% of custom fee schedule,3.58,100,,,fee schedule,Pays 100% Medicare OPPS,4.65,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,3.58,100,,,fee schedule,Pays 100% Medicare OPPS,3.22,121.5,
.MYCOBACTERIA STAIN,3000218,CDM,306,RC,87206,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.39,100,,,fee schedule,Pays 100% Medicare OPPS,5.39,100,,,fee schedule,Pays 100% Medicare OPPS,5.39,100,,,fee schedule,Pays 100% Medicare OPPS,7,130,,,fee schedule,Pays 130% Medicare OPPS,8.12,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.49,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.45,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.39,100,,,fee schedule,Pays 100% Medicare OPPS,4.85,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,8.12,120.37,,,fee schedule,120.37% of custom fee schedule,5.39,100,,,fee schedule,Pays 100% Medicare OPPS,7,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.39,100,,,fee schedule,Pays 100% Medicare OPPS,4.85,121.5,
.PROTEIN ELECT (IMMUNO),3000241,CDM,301,RC,84165,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,13.96,130,,,fee schedule,Pays 130% Medicare OPPS,16.26,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,10.95,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,16.91,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,9.66,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,16.26,120.37,,,fee schedule,120.37% of custom fee schedule,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,13.96,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,9.66,121.5,
PROTEIN BODY FLUID,3000242,CDM,300,RC,84157,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,4,100,,,fee schedule,Pays 100% Medicare OPPS,4,100,,,fee schedule,Pays 100% Medicare OPPS,4,100,,,fee schedule,Pays 100% Medicare OPPS,5.2,130,,,fee schedule,Pays 130% Medicare OPPS,5.55,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.08,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,5.77,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,4,100,,,fee schedule,Pays 100% Medicare OPPS,3.6,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,5.55,120.37,,,fee schedule,120.37% of custom fee schedule,4,100,,,fee schedule,Pays 100% Medicare OPPS,5.2,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,4,100,,,fee schedule,Pays 100% Medicare OPPS,3.6,121.5,
RAST EACH ALLERGEN,3000253,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
.T PROT ELEC F&Q(SPEP W IM,3000295,CDM,301,RC,84165,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,13.96,130,,,fee schedule,Pays 130% Medicare OPPS,16.26,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,10.95,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,16.91,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,9.66,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,16.26,120.37,,,fee schedule,120.37% of custom fee schedule,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,13.96,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,9.66,121.5,
RAST FOR HONEYBEE,3000397,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR ALDER TREE,3000398,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR ALMOND,3000399,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR ALTERNARIA TENUIS,3000400,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR APPLE,3000401,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR ASPARAGUS,3000402,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR AVOCADO,3000403,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR BAHIA GRASS,3000404,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR BAKER'S YEAST,3000405,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR BANANA,3000406,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR BARLEY,3000407,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR GREEN BEAN,3000408,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR BEECH TREE,3000409,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR BEEF,3000410,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR BERMUDA GRASS,3000411,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR BIRCH TREE,3000412,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR BLUEBERRY,3000413,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR BOTRYTIS,3000414,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR BRAZIL NUT,3000415,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR BREWER'S YEAST,3000416,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR BUCKWHEAT,3000417,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR CABBAGE,3000418,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR CANARY GRASS,3000419,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR CARELESS WEED,3000420,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR CARROT,3000421,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR CASEIN,3000422,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR CAT DANDER,3000423,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR CEDAR MT,3000424,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR CELERY,3000425,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR CEREAL GP,3000426,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR CHEDDAR CHEESE,3000427,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR CHICKEN MEAT,3000428,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR CHILI PEPPER,3000429,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR CHOCOLATE,3000430,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR CLAM,3000431,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR COCKLEBUR,3000432,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR COCKROACH,3000433,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR COCONUT,3000434,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR COD FISH,3000435,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR COFFEE,3000436,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR CORN,3000437,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR CORN POLLEN,3000438,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR COTTONWOOD TREE,3000439,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR COW DANDER,3000440,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR CRAB,3000441,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR CUCUMBER,3000442,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR DANDELION,3000443,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
.RAST FOR DOG EPITHELIUM,3000444,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR EGG WHITE,3000445,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR EGG YOLK,3000446,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
3RD RAST FOR EGG WHOLE,3000447,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR ELM TREE,3000448,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR EUCALYPTUS TREE,3000449,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR FEATHER MIX,3000450,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR GARLIC,3000451,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR GLUTEN,3000452,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR GOLDENROD,3000453,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR GREEN PEA,3000454,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR HAZELNUT(FOOD),3000455,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR HORSE DANDER,3000456,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR HOUSE DUST(GREER),3000457,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR HOUSE DUST(HOLLISTER STEIR),3000458,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR FIRE ANT,3000459,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR JOHNSON GRASS,3000460,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR JUNE GRASS(KY BLUE),3000461,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR KIWI FRUIT,3000462,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR LAMB'S QTR,3000463,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR LATEX,3000464,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR LETTUCE,3000465,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR LOBSTER,3000466,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR MALT,3000467,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR MANGO,3000468,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR MAPLE TREE,3000469,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR MEADOW FESCUE,3000470,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR MELON,3000471,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR MILK,3000472,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR MOLD ALLERGEN GP,3000473,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR MUGWORT,3000474,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR MULBERRY WHITE,3000475,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR MUSTARD,3000476,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR NUT MIX GP,3000477,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR OAK TREE,3000478,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR OAT,3000479,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR OLIVE TREE,3000480,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR ONION,3000481,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR ORANGE,3000482,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR ORCHARD GRASS,3000483,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR OVALBUMIN,3000484,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR OVAMUCOID,3000485,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR OYSTER,3000486,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR PAPAYA,3000487,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR PAPER WASP,3000488,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR PARSLEY,3000489,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR PEACH,3000490,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR PEANUT,3000491,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR PECAN NUT,3000492,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR PECAN TREE,3000493,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR PEPPER BLACK,3000494,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR PEPPER GREEN,3000495,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR PERENNIAL RYE,3000496,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR WHITE PINE,3000497,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR PINTO BEAN,3000498,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR PISTACHIO NUT,3000499,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR PORK,3000500,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR POTATO,3000501,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR RAGWEED COMMON,3000502,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR RAGWEED FALSE,3000503,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR RAGWEED GAINT,3000504,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR RAGWEED WESTERN,3000505,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR RED TOP GRASS,3000506,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR RICE,3000507,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR ROUGH MARSH ELDER,3000508,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR ROUGH PIGWEED,3000509,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR RUSSIAN THISTLE,3000510,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR SALAD ALLERGEN GRP,3000511,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR SALMON,3000512,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR SEAFOOD,3000514,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR SESAME SEED,3000515,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR SHEEP SORREL,3000516,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR SHRIMP,3000517,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR SOYBEAN,3000518,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR STINGING INSECT GROUP,3000519,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR STRAWBERRY,3000520,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR SUNFLOWER SEED,3000521,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR SWEET POTATO,3000522,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR SWEET VERNAL GRASS,3000523,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR SYCAMORE TREE,3000524,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR TIMOTHY GRASS,3000525,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR TOMATOES,3000526,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR TROUT,3000527,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR TUNA,3000528,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR TURKEY MEAT,3000529,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR VEGETABLE GRP,3000530,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
"RAST FOR WALNUT, FOOD",3000531,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR WALNUT TREE,3000532,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR WHEAT,3000533,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR WHITE ASH TREE,3000534,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR WHITE BEAN,3000535,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR WHITE FACE HORNET,3000536,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR WILLOW TREE,3000537,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR WORMWOOD,3000538,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR YELLOW HORNET,3000539,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR YELLOW JACKET,3000540,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR PENICILLIUM MOLD,3000596,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR HOPS,3000597,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR ASPERGILLIS (NIGER),3000598,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR DUST MITE (HOUSE),3000599,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
DUST MITE D1,3000603,CDM,301,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
D2 DUST MITE,3000604,CDM,300,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
.ISOLATION OR EXT NA TPMT,3000630,CDM,301,RC,83891,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,33.75,100,,,fee schedule,Pays 100% Medicare OPPS,33.75,100,,,fee schedule,Pays 100% Medicare OPPS,33.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
".MOLECULAR DIAG, ISOL TPMT",3000631,CDM,301,RC,83890,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,33.75,100,,,fee schedule,Pays 100% Medicare OPPS,33.75,100,,,fee schedule,Pays 100% Medicare OPPS,33.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
.MOLECULAR AMP TPMT,3000632,CDM,301,RC,83901,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,33.75,100,,,fee schedule,Pays 100% Medicare OPPS,33.75,100,,,fee schedule,Pays 100% Medicare OPPS,33.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
.MOLECULAR I&R TPMT,3000633,CDM,301,RC,83912,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,33.75,100,,,fee schedule,Pays 100% Medicare OPPS,33.75,100,,,fee schedule,Pays 100% Medicare OPPS,33.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
.MUTATION ID TPMT,3000634,CDM,301,RC,81335,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,174.81,100,,,fee schedule,Pays 100% Medicare OPPS,174.81,100,,,fee schedule,Pays 100% Medicare OPPS,174.81,100,,,fee schedule,Pays 100% Medicare OPPS,227.25,130,,,fee schedule,Pays 130% Medicare OPPS,168.34,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,178.3,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,175.06,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,174.81,100,,,fee schedule,Pays 100% Medicare OPPS,157.32,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,168.34,120.37,,,fee schedule,120.37% of custom fee schedule,174.81,100,,,fee schedule,Pays 100% Medicare OPPS,227.25,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,174.81,100,,,fee schedule,Pays 100% Medicare OPPS,76.28,227.25,
RAST FOR CRAYFISH,3000651,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR RABBIT EPITHELIAL,3000654,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR CASHEW,3000666,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
I-STAT TCO2,3000681,CDM,301,RC,82374,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,4.88,100,,,fee schedule,Pays 100% Medicare OPPS,4.88,100,,,fee schedule,Pays 100% Medicare OPPS,4.88,100,,,fee schedule,Pays 100% Medicare OPPS,6.34,130,,,fee schedule,Pays 130% Medicare OPPS,7.4,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.97,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,7.7,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,4.88,100,,,fee schedule,Pays 100% Medicare OPPS,4.39,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.4,120.37,,,fee schedule,120.37% of custom fee schedule,4.88,100,,,fee schedule,Pays 100% Medicare OPPS,6.34,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,4.88,100,,,fee schedule,Pays 100% Medicare OPPS,4.39,121.5,
RAST FOR HICKORY WHITE,3000692,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR WHEY,3000693,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR ALPHA LACTA ALBUMIN,3000694,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR BETA LACTOGLOBULIN,3000695,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR DUST MITE (DERMATOPHAGOIDES PTE,3000712,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR DUST MITE (FARINAE),3000713,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR DOG DANDER,3000714,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR ASPERGILLIS (FUMIGATUS),3000715,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
.CELL COUNT CSF,3000719,CDM,300,RC,89050,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,6.13,130,,,fee schedule,Pays 130% Medicare OPPS,7.16,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.81,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,7.45,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.24,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.16,120.37,,,fee schedule,120.37% of custom fee schedule,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,6.13,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.24,121.5,
RAST FOR CEPHALOSPORIN IGE,3000722,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR ERYTHROMYCIN,3000723,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR MUCOR RACEMOSUS,3000725,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
RAST FOR R. NIGRICANS,3000726,CDM,302,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
3RD FACTOR VIII,3000812,CDM,300,RC,85240,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,17.89,100,,,fee schedule,Pays 100% Medicare OPPS,17.89,100,,,fee schedule,Pays 100% Medicare OPPS,17.89,100,,,fee schedule,Pays 100% Medicare OPPS,23.27,130,,,fee schedule,Pays 130% Medicare OPPS,27.11,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.25,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,28.19,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,17.89,100,,,fee schedule,Pays 100% Medicare OPPS,16.1,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,27.11,120.37,,,fee schedule,120.37% of custom fee schedule,17.89,100,,,fee schedule,Pays 100% Medicare OPPS,23.27,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,17.89,100,,,fee schedule,Pays 100% Medicare OPPS,16.1,121.5,
OCCULT BLOOD STOOL #1,3082270,CDM,301,RC,82270,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,4.38,100,,,fee schedule,Pays 100% Medicare OPPS,4.38,100,,,fee schedule,Pays 100% Medicare OPPS,4.38,100,,,fee schedule,Pays 100% Medicare OPPS,5.69,130,,,fee schedule,Pays 130% Medicare OPPS,4.86,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.46,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,5.06,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,4.38,100,,,fee schedule,Pays 100% Medicare OPPS,3.94,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,4.86,120.37,,,fee schedule,120.37% of custom fee schedule,4.38,100,,,fee schedule,Pays 100% Medicare OPPS,5.69,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,4.38,100,,,fee schedule,Pays 100% Medicare OPPS,3.94,121.5,
OCCULT BLOOD-other,3082271,CDM,301,RC,82271,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.32,100,,,fee schedule,Pays 100% Medicare OPPS,5.32,100,,,fee schedule,Pays 100% Medicare OPPS,5.32,100,,,fee schedule,Pays 100% Medicare OPPS,6.91,130,,,fee schedule,Pays 130% Medicare OPPS,4.86,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.42,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,5.06,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.32,100,,,fee schedule,Pays 100% Medicare OPPS,4.78,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,4.86,120.37,,,fee schedule,120.37% of custom fee schedule,5.32,100,,,fee schedule,Pays 100% Medicare OPPS,6.91,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.32,100,,,fee schedule,Pays 100% Medicare OPPS,4.78,121.5,
.OCCULT BLOOD DIGITAL EXAM,3082272,CDM,301,RC,82272,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,4.23,100,,,fee schedule,Pays 100% Medicare OPPS,4.23,100,,,fee schedule,Pays 100% Medicare OPPS,4.23,100,,,fee schedule,Pays 100% Medicare OPPS,5.49,130,,,fee schedule,Pays 130% Medicare OPPS,4.86,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.31,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,5.06,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,4.23,100,,,fee schedule,Pays 100% Medicare OPPS,3.8,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,4.86,120.37,,,fee schedule,120.37% of custom fee schedule,4.23,100,,,fee schedule,Pays 100% Medicare OPPS,5.49,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,4.23,100,,,fee schedule,Pays 100% Medicare OPPS,3.8,121.5,
CO2,3082374,CDM,301,RC,82374,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,4.88,100,,,fee schedule,Pays 100% Medicare OPPS,4.88,100,,,fee schedule,Pays 100% Medicare OPPS,4.88,100,,,fee schedule,Pays 100% Medicare OPPS,6.34,130,,,fee schedule,Pays 130% Medicare OPPS,7.4,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.97,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,7.7,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,4.88,100,,,fee schedule,Pays 100% Medicare OPPS,4.39,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.4,120.37,,,fee schedule,120.37% of custom fee schedule,4.88,100,,,fee schedule,Pays 100% Medicare OPPS,6.34,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,4.88,100,,,fee schedule,Pays 100% Medicare OPPS,4.39,121.5,
"CRYOGLOBULIN, QUALITATIVE",3082595,CDM,301,RC,82595,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,8.41,130,,,fee schedule,Pays 130% Medicare OPPS,9.8,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.59,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,10.19,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,5.82,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,9.8,120.37,,,fee schedule,120.37% of custom fee schedule,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,8.41,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,5.82,121.5,
Blood test to measure the level of lipoproteins in the blood,3083718,CDM,301,RC,83718,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,8.19,100,,,fee schedule,Pays 100% Medicare OPPS,8.19,100,,,fee schedule,Pays 100% Medicare OPPS,8.19,100,,,fee schedule,Pays 100% Medicare OPPS,10.64,130,,,fee schedule,Pays 130% Medicare OPPS,12.4,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.35,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,12.89,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,8.19,100,,,fee schedule,Pays 100% Medicare OPPS,7.37,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,12.4,120.37,,,fee schedule,120.37% of custom fee schedule,8.19,100,,,fee schedule,Pays 100% Medicare OPPS,10.64,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,8.19,100,,,fee schedule,Pays 100% Medicare OPPS,7.37,121.5,
PROTEIN TOTAL SERUM,3084155,CDM,301,RC,84155,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,3.67,100,,,fee schedule,Pays 100% Medicare OPPS,3.67,100,,,fee schedule,Pays 100% Medicare OPPS,3.67,100,,,fee schedule,Pays 100% Medicare OPPS,4.77,130,,,fee schedule,Pays 130% Medicare OPPS,5.55,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3.74,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,5.77,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,3.67,100,,,fee schedule,Pays 100% Medicare OPPS,3.3,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,5.55,120.37,,,fee schedule,120.37% of custom fee schedule,3.67,100,,,fee schedule,Pays 100% Medicare OPPS,4.77,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,3.67,100,,,fee schedule,Pays 100% Medicare OPPS,3.3,121.5,
PROTEIN CSF,3084157,CDM,301,RC,84157,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,4,100,,,fee schedule,Pays 100% Medicare OPPS,4,100,,,fee schedule,Pays 100% Medicare OPPS,4,100,,,fee schedule,Pays 100% Medicare OPPS,5.2,130,,,fee schedule,Pays 130% Medicare OPPS,5.55,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.08,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,5.77,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,4,100,,,fee schedule,Pays 100% Medicare OPPS,3.6,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,5.55,120.37,,,fee schedule,120.37% of custom fee schedule,4,100,,,fee schedule,Pays 100% Medicare OPPS,5.2,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,4,100,,,fee schedule,Pays 100% Medicare OPPS,3.6,121.5,
SEX HORMONE BINDING GLOBULIN,3084270,CDM,309,RC,84270,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,21.73,100,,,fee schedule,Pays 100% Medicare OPPS,21.73,100,,,fee schedule,Pays 100% Medicare OPPS,21.73,100,,,fee schedule,Pays 100% Medicare OPPS,28.24,130,,,fee schedule,Pays 130% Medicare OPPS,32.89,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.16,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,34.2,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,21.73,100,,,fee schedule,Pays 100% Medicare OPPS,19.55,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,32.89,120.37,,,fee schedule,120.37% of custom fee schedule,21.73,100,,,fee schedule,Pays 100% Medicare OPPS,28.24,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,21.73,100,,,fee schedule,Pays 100% Medicare OPPS,19.55,121.5,
FETAL SCREEN,3085461,CDM,305,RC,85461,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,9.36,100,,,fee schedule,Pays 100% Medicare OPPS,9.36,100,,,fee schedule,Pays 100% Medicare OPPS,9.36,100,,,fee schedule,Pays 100% Medicare OPPS,12.16,130,,,fee schedule,Pays 130% Medicare OPPS,10.03,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.54,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,10.43,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,9.36,100,,,fee schedule,Pays 100% Medicare OPPS,8.42,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,10.03,120.37,,,fee schedule,120.37% of custom fee schedule,9.36,100,,,fee schedule,Pays 100% Medicare OPPS,12.16,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,9.36,100,,,fee schedule,Pays 100% Medicare OPPS,8.42,121.5,
.ALLERGEN (RAST PROFILE),3086003,CDM,301,RC,86003,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,121.5,
CANDIDA ANTIBODIES,3086628,CDM,300,RC,86628,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,12.01,100,,,fee schedule,Pays 100% Medicare OPPS,12.01,100,,,fee schedule,Pays 100% Medicare OPPS,12.01,100,,,fee schedule,Pays 100% Medicare OPPS,15.61,130,,,fee schedule,Pays 130% Medicare OPPS,18.18,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.25,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,18.9,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,12.01,100,,,fee schedule,Pays 100% Medicare OPPS,10.8,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,18.18,120.37,,,fee schedule,120.37% of custom fee schedule,12.01,100,,,fee schedule,Pays 100% Medicare OPPS,15.61,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,12.01,100,,,fee schedule,Pays 100% Medicare OPPS,10.8,121.5,
.ENTEROVIRUS(COXSACKIE A),3086658,CDM,302,RC,86658,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,13.03,100,,,fee schedule,Pays 100% Medicare OPPS,13.03,100,,,fee schedule,Pays 100% Medicare OPPS,13.03,100,,,fee schedule,Pays 100% Medicare OPPS,16.93,130,,,fee schedule,Pays 130% Medicare OPPS,19.72,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.29,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,20.5,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,13.03,100,,,fee schedule,Pays 100% Medicare OPPS,11.72,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,19.72,120.37,,,fee schedule,120.37% of custom fee schedule,13.03,100,,,fee schedule,Pays 100% Medicare OPPS,16.93,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,13.03,100,,,fee schedule,Pays 100% Medicare OPPS,11.72,121.5,
Medical test to find an infection,3086668,CDM,302,RC,87081,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,6.63,100,,,fee schedule,Pays 100% Medicare OPPS,6.63,100,,,fee schedule,Pays 100% Medicare OPPS,6.63,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,130,,,fee schedule,Pays 130% Medicare OPPS,10.03,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.76,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,10.43,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,6.63,100,,,fee schedule,Pays 100% Medicare OPPS,5.96,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,10.03,120.37,,,fee schedule,120.37% of custom fee schedule,6.63,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,6.63,100,,,fee schedule,Pays 100% Medicare OPPS,5.96,121.5,
GIARDIA ANTIGEN STOOL,3086674,CDM,302,RC,87329,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,15.57,130,,,fee schedule,Pays 130% Medicare OPPS,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.21,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,18.88,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,10.78,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,15.57,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,10.78,121.5,
HIV BY WESTERN BLOT,3086689,CDM,300,RC,86689,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,25.15,130,,,fee schedule,Pays 130% Medicare OPPS,25.42,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.73,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,26.44,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,17.41,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,25.42,120.37,,,fee schedule,120.37% of custom fee schedule,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,25.15,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,17.41,121.5,
Blood test to identify bacteria that may be contributing to symptoms in the gastrointestinal tract,3087046,CDM,306,RC,87046,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,12.27,130,,,fee schedule,Pays 130% Medicare OPPS,3.57,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.62,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,3.72,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,8.49,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,3.57,120.37,,,fee schedule,120.37% of custom fee schedule,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,12.27,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,3.57,121.5,
PIN WORM PREP,3087172,CDM,306,RC,87172,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,5.55,130,,,fee schedule,Pays 130% Medicare OPPS,6.45,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.35,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,6.71,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,3.84,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,6.45,120.37,,,fee schedule,120.37% of custom fee schedule,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,5.55,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,3.84,121.5,
.AFB SMEAR (AFB S&C),3087206,CDM,306,RC,87206,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.39,100,,,fee schedule,Pays 100% Medicare OPPS,5.39,100,,,fee schedule,Pays 100% Medicare OPPS,5.39,100,,,fee schedule,Pays 100% Medicare OPPS,7,130,,,fee schedule,Pays 130% Medicare OPPS,8.12,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.49,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,8.45,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.39,100,,,fee schedule,Pays 100% Medicare OPPS,4.85,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,8.12,120.37,,,fee schedule,120.37% of custom fee schedule,5.39,100,,,fee schedule,Pays 100% Medicare OPPS,7,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.39,100,,,fee schedule,Pays 100% Medicare OPPS,4.85,121.5,
A lab test to screen for evidence of vaginal infection,3087210,CDM,306,RC,87210,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,7.56,130,,,fee schedule,Pays 130% Medicare OPPS,6.45,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.93,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,6.71,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,5.23,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,6.45,120.37,,,fee schedule,120.37% of custom fee schedule,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,7.56,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,5.23,121.5,
"3RD CRYPTOSPORIDIUM, STOOL",3087328,CDM,306,RC,87328,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,13.82,100,,,fee schedule,Pays 100% Medicare OPPS,13.82,100,,,fee schedule,Pays 100% Medicare OPPS,13.82,100,,,fee schedule,Pays 100% Medicare OPPS,17.96,130,,,fee schedule,Pays 130% Medicare OPPS,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.09,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,18.88,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,13.82,100,,,fee schedule,Pays 100% Medicare OPPS,12.43,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,13.82,100,,,fee schedule,Pays 100% Medicare OPPS,17.96,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,13.82,100,,,fee schedule,Pays 100% Medicare OPPS,12.43,121.5,
O&P SMEAR,3087330,CDM,306,RC,87177,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,8.9,100,,,fee schedule,Pays 100% Medicare OPPS,8.9,100,,,fee schedule,Pays 100% Medicare OPPS,8.9,100,,,fee schedule,Pays 100% Medicare OPPS,11.57,130,,,fee schedule,Pays 130% Medicare OPPS,13.47,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.07,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,14.01,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,8.9,100,,,fee schedule,Pays 100% Medicare OPPS,8.01,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,13.47,120.37,,,fee schedule,120.37% of custom fee schedule,8.9,100,,,fee schedule,Pays 100% Medicare OPPS,11.57,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,8.9,100,,,fee schedule,Pays 100% Medicare OPPS,8.01,121.5,
.INFLUENZA A RAPID TEST,3087400,CDM,300,RC,87400,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,14.13,100,,,fee schedule,Pays 100% Medicare OPPS,14.13,100,,,fee schedule,Pays 100% Medicare OPPS,14.13,100,,,fee schedule,Pays 100% Medicare OPPS,18.36,130,,,fee schedule,Pays 130% Medicare OPPS,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.41,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,18.88,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,14.13,100,,,fee schedule,Pays 100% Medicare OPPS,12.71,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,14.13,100,,,fee schedule,Pays 100% Medicare OPPS,18.36,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,14.13,100,,,fee schedule,Pays 100% Medicare OPPS,12.71,121.5,
CELL CO JOINT FLUID/DIFF,3089050,CDM,309,RC,89050,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,6.13,130,,,fee schedule,Pays 130% Medicare OPPS,7.16,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.81,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,7.45,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.24,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,7.16,120.37,,,fee schedule,120.37% of custom fee schedule,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,6.13,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,4.72,100,,,fee schedule,Pays 100% Medicare OPPS,4.24,121.5,
CELL CO BODY FLUID W DIF,3089051,CDM,309,RC,89051,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,5.6,100,,,fee schedule,Pays 100% Medicare OPPS,5.6,100,,,fee schedule,Pays 100% Medicare OPPS,5.6,100,,,fee schedule,Pays 100% Medicare OPPS,7.28,130,,,fee schedule,Pays 130% Medicare OPPS,2.66,120.37,,,fee schedule,120.37% of custom fee schedule,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.71,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,2.77,125.18,,,fee schedule,125.18% of custom fee schedule,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,5.6,100,,,fee schedule,Pays 100% Medicare OPPS,5.03,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,2.66,120.37,,,fee schedule,120.37% of custom fee schedule,5.6,100,,,fee schedule,Pays 100% Medicare OPPS,7.28,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,5.6,100,,,fee schedule,Pays 100% Medicare OPPS,2.66,121.5,
CT REDI-CAT,4200011,CDM,255,RC,A4641,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,27.5,121.5,
MM 3D MAMMO BIL SCREENING,4300203,CDM,403,RC,77063,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,21.26,100,,,fee schedule,Pays 100% Medicare OPPS,21.26,100,,,fee schedule,Pays 100% Medicare OPPS,21.26,100,,,fee schedule,Pays 100% Medicare OPPS,27.94,130,,,fee schedule,Pays 130% Medicare OPPS,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,75.87,56.5,,,percent of total billed charges,56.5 percent of total billed charges,21.69,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,21.26,100,,,fee schedule,Pays 100% Medicare OPPS,19.13,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,21.49,100,,,fee schedule,Pays 100% Medicare OPPS,27.94,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,21.26,100,,,fee schedule,Pays 100% Medicare OPPS,19.13,121.5,
MM 3D MAMMO BIL DIAGNOSTIC,4300205,CDM,401,RC,G0279,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,21.26,100,,,fee schedule,Pays 100% Medicare OPPS,21.26,100,,,fee schedule,Pays 100% Medicare OPPS,21.26,100,,,fee schedule,Pays 100% Medicare OPPS,27.94,130,,,fee schedule,Pays 130% Medicare OPPS,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,75.87,56.5,,,percent of total billed charges,56.5 percent of total billed charges,21.69,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,21.26,100,,,fee schedule,Pays 100% Medicare OPPS,19.13,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,21.49,100,,,fee schedule,Pays 100% Medicare OPPS,27.94,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,21.26,100,,,fee schedule,Pays 100% Medicare OPPS,19.13,121.5,
MM 3D MAMMO UNILATERAL LEFT,4300207,CDM,401,RC,G0279,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,21.26,100,,,fee schedule,Pays 100% Medicare OPPS,21.26,100,,,fee schedule,Pays 100% Medicare OPPS,21.26,100,,,fee schedule,Pays 100% Medicare OPPS,27.94,130,,,fee schedule,Pays 130% Medicare OPPS,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,75.87,56.5,,,percent of total billed charges,56.5 percent of total billed charges,21.69,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,21.26,100,,,fee schedule,Pays 100% Medicare OPPS,19.13,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,21.49,100,,,fee schedule,Pays 100% Medicare OPPS,27.94,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,21.26,100,,,fee schedule,Pays 100% Medicare OPPS,19.13,121.5,
MM 3D MAMMO UNILATERAL RIGHT,4300208,CDM,401,RC,G0279,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,21.26,100,,,fee schedule,Pays 100% Medicare OPPS,21.26,100,,,fee schedule,Pays 100% Medicare OPPS,21.26,100,,,fee schedule,Pays 100% Medicare OPPS,27.94,130,,,fee schedule,Pays 130% Medicare OPPS,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,75.87,56.5,,,percent of total billed charges,56.5 percent of total billed charges,21.69,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,21.26,100,,,fee schedule,Pays 100% Medicare OPPS,19.13,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,21.49,100,,,fee schedule,Pays 100% Medicare OPPS,27.94,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,21.26,100,,,fee schedule,Pays 100% Medicare OPPS,19.13,121.5,
KNEE WRAP STABILIZER 929140,5007542,CDM,270,RC,,,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
"Machines designed to pump cold water into an inflatable wrap or brace, compressing the enveloped area of the body",5197016,CDM,430,RC,97016,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,11.4,100,,,fee schedule,Pays 100% Medicare OPPS,11.4,100,,,fee schedule,Pays 100% Medicare OPPS,11.4,100,,,fee schedule,Pays 100% Medicare OPPS,14.59,130,,,fee schedule,Pays 130% Medicare OPPS,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.63,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,11.4,100,,,fee schedule,Pays 100% Medicare OPPS,10.26,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.22,100,,,fee schedule,Pays 100% Medicare OPPS,14.59,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,11.4,100,,,fee schedule,Pays 100% Medicare OPPS,10.26,121.5,
SMOKING CESSATION,5500007,CDM,942,RC,99406,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,23.6,100,,,fee schedule,Pays 100% Medicare OPPS,23.6,100,,,fee schedule,Pays 100% Medicare OPPS,23.6,100,,,fee schedule,Pays 100% Medicare OPPS,33.93,130,,,fee schedule,Pays 130% Medicare OPPS,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,24.07,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,23.6,100,,,fee schedule,Pays 100% Medicare OPPS,21.24,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,26.1,100,,,fee schedule,Pays 100% Medicare OPPS,33.93,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,23.6,100,,,fee schedule,Pays 100% Medicare OPPS,21.24,121.5,
GEST DIABETES MNGT,6000620,CDM,942,RC,G0108,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,53.06,100,,,fee schedule,Pays 100% Medicare OPPS,53.06,100,,,fee schedule,Pays 100% Medicare OPPS,53.06,100,,,fee schedule,Pays 100% Medicare OPPS,67.82,130,,,fee schedule,Pays 130% Medicare OPPS,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,54.12,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,53.06,100,,,fee schedule,Pays 100% Medicare OPPS,47.75,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,52.17,100,,,fee schedule,Pays 100% Medicare OPPS,67.82,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,53.06,100,,,fee schedule,Pays 100% Medicare OPPS,27.5,121.5,
IND THERAPEUTIC DIET CONS,6000848,CDM,942,RC,97802,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,35.07,100,,,fee schedule,Pays 100% Medicare OPPS,35.07,100,,,fee schedule,Pays 100% Medicare OPPS,35.07,100,,,fee schedule,Pays 100% Medicare OPPS,40.09,130,,,fee schedule,Pays 130% Medicare OPPS,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,35.77,102,,,fee schedule,Pays 102% Medicare OPPS,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,35.07,100,,,fee schedule,Pays 100% Medicare OPPS,31.56,90,,,fee schedule,Pays 90% Medicare OPPS,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,30.84,100,,,fee schedule,Pays 100% Medicare OPPS,40.09,130,,,fee schedule,Pays 130% Medicare OPPS,114.75,85,,,percent of total billed charges,85% of total billed charges,35.07,100,,,fee schedule,Pays 100% Medicare OPPS,27.5,121.5,
BIPAP CAP MASK MEDIUM 1061728,7900017,CDM,272,RC,A7027,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
BIPAP CAP MASK SMALL 1061727,7900019,CDM,272,RC,A7027,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
BIPAP CAP MASK SMALL 1072627,7900021,CDM,272,RC,A7027,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
BIPAP CAP MASK MEDIUM 1072628,7900022,CDM,272,RC,A7027,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
BIPAP CAP MASK LARGE 1072629,7900023,CDM,272,RC,A7027,HCPCS,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
BOVIE MACH/HANDTROL,7901009,CDM,270,RC,,,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
MICRO WIRE DRIVER,7901181,CDM,270,RC,,,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
LAP PACK,7901193,CDM,270,RC,,,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
T & A PACK,7901196,CDM,270,RC,,,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
PREP TRAY,7901212,CDM,270,RC,,,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
MORGAN LENS,7905135,CDM,272,RC,,,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
BRACE DURA STEPPER SMALL,7905915,CDM,270,RC,,,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
BRACE DURA STEPPER MED,7905916,CDM,270,RC,,,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
NEEDLE INTRAOSSEOUS CAREFUSION DIN1518X,7905934,CDM,272,RC,,,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
...DISP INCENT SPIRO SET,7919305,CDM,270,RC,,,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
IRRIG. SET/FOUR BAG,7950137,CDM,270,RC,,,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
GASTROSTOMY TUBE MIC ADULT 22FR,7950201,CDM,270,RC,,,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
GASTROSTOMY TUBE MIC ADULT 24FR,7950202,CDM,270,RC,,,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
GASTROSTOMY TUBE MAGNA PORT 20FR,7950203,CDM,270,RC,,,Outpatient,,,135,108,,114.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,121.5,90,,,percent of total billed charges,90% of total billed charges,47.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,92.75,68.7,,,percent of total billed charges,68.7% of total billed charges,108,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.3,58,,,percent of total billed charges,58% of total billed charges,27.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.5,121.5,
HUMIDIFICATION CHAMBER AH290,7950313,CDM,270,RC,,,Outpatient,,,135.6,108.48,,115.26,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.62,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.61,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.61,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.61,56.5,,,percent of total billed charges,56.5 percent of total billed charges,76.61,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,122.04,90,,,percent of total billed charges,90% of total billed charges,47.46,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,93.16,68.7,,,percent of total billed charges,68.7% of total billed charges,108.48,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,78.65,58,,,percent of total billed charges,58% of total billed charges,27.62,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,115.26,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.62,122.04,
TROCAR KII BLUNT TIP C0R85,1570083,CDM,270,RC,,,Outpatient,,,140,112,,119,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,126,90,,,percent of total billed charges,90% of total billed charges,49,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,96.18,68.7,,,percent of total billed charges,68.7% of total billed charges,112,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,81.2,58,,,percent of total billed charges,58% of total billed charges,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,119,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,28.52,126,
OBTURATOR KII OPTICAL CTR73,1570085,CDM,270,RC,,,Outpatient,,,140,112,,119,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,126,90,,,percent of total billed charges,90% of total billed charges,49,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,96.18,68.7,,,percent of total billed charges,68.7% of total billed charges,112,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,81.2,58,,,percent of total billed charges,58% of total billed charges,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,119,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,28.52,126,
K-WIRE 1.6mm,1570352,CDM,278,RC,C1713,HCPCS,Both,,,140,112,,119,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,126,90,,,percent of total billed charges,90% of total billed charges,49,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,96.18,68.7,,,percent of total billed charges,68.7% of total billed charges,112,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,81.2,58,,,percent of total billed charges,58% of total billed charges,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,119,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,28.52,126,
SUTURE 3-0 VLOC 90 GS-21 9,1570628,CDM,272,RC,,,Outpatient,,,140,112,,119,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,126,90,,,percent of total billed charges,90% of total billed charges,49,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,96.18,68.7,,,percent of total billed charges,68.7% of total billed charges,112,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,81.2,58,,,percent of total billed charges,58% of total billed charges,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,119,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,28.52,126,
SUTURE 2-0 VLOC 90 GS-22 9,1570629,CDM,272,RC,,,Outpatient,,,140,112,,119,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,126,90,,,percent of total billed charges,90% of total billed charges,49,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,96.18,68.7,,,percent of total billed charges,68.7% of total billed charges,112,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,81.2,58,,,percent of total billed charges,58% of total billed charges,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,119,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,28.52,126,
OBTURATOR KII OPTICAL CTR71,1570791,CDM,270,RC,,,Outpatient,,,140,112,,119,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,126,90,,,percent of total billed charges,90% of total billed charges,49,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,96.18,68.7,,,percent of total billed charges,68.7% of total billed charges,112,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,81.2,58,,,percent of total billed charges,58% of total billed charges,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,119,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,28.52,126,
PERSANTINE (DIPYRIDAMOLE) INJ PER 10MG,2605188,CDM,636,RC,J1245,HCPCS,Both,,,140,112,,119,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.45,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,126,90,,,percent of total billed charges,90% of total billed charges,4.63,125.18,,,fee schedule,125.18% of custom fee schedule,96.18,68.7,,,percent of total billed charges,68.7% of total billed charges,112,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,81.2,58,,,percent of total billed charges,58% of total billed charges,4.45,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,119,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.45,126,
BENTYL (DICYCLOMINE HCL) INJ 20MG,2610133,CDM,636,RC,,,Both,,,140,112,,119,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,126,90,,,percent of total billed charges,90% of total billed charges,49,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,96.18,68.7,,,percent of total billed charges,68.7% of total billed charges,112,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,81.2,58,,,percent of total billed charges,58% of total billed charges,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,119,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,28.52,126,
ACCUHIST DM DROPS (BR/DM/PSE) : 30ML,2660005,CDM,637,RC,,,Outpatient,,,140,112,,119,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,126,90,,,percent of total billed charges,90% of total billed charges,49,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,96.18,68.7,,,percent of total billed charges,68.7% of total billed charges,112,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,81.2,58,,,percent of total billed charges,58% of total billed charges,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,119,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,28.52,126,
"MOLECULAR DIAG,AMP PNA",3000213,CDM,301,RC,83901,HCPCS,Outpatient,,,140,112,,119,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,126,90,,,percent of total billed charges,90% of total billed charges,49,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,96.18,68.7,,,percent of total billed charges,68.7% of total billed charges,112,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,81.2,58,,,percent of total billed charges,58% of total billed charges,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,119,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,28.52,126,
BIOPSY INSTRUMENT MONOPTY 121410,7950206,CDM,272,RC,,,Outpatient,,,140,112,,119,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,126,90,,,percent of total billed charges,90% of total billed charges,49,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,96.18,68.7,,,percent of total billed charges,68.7% of total billed charges,112,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,81.2,58,,,percent of total billed charges,58% of total billed charges,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,119,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,28.52,126,
BRA SURGICAL BREAST SUPPORT LARGE,7950304,CDM,270,RC,,,Outpatient,,,140,112,,119,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,126,90,,,percent of total billed charges,90% of total billed charges,49,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,96.18,68.7,,,percent of total billed charges,68.7% of total billed charges,112,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,81.2,58,,,percent of total billed charges,58% of total billed charges,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,119,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,28.52,126,
BRA SURGICAL BREAST SUPPORT XLARGE,7950305,CDM,270,RC,,,Outpatient,,,140,112,,119,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,126,90,,,percent of total billed charges,90% of total billed charges,49,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,96.18,68.7,,,percent of total billed charges,68.7% of total billed charges,112,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,81.2,58,,,percent of total billed charges,58% of total billed charges,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,119,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,28.52,126,
BRA SURGICAL BREAST SUPPORT 2XL,7950306,CDM,270,RC,,,Outpatient,,,140,112,,119,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,126,90,,,percent of total billed charges,90% of total billed charges,49,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,96.18,68.7,,,percent of total billed charges,68.7% of total billed charges,112,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,81.2,58,,,percent of total billed charges,58% of total billed charges,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,119,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,28.52,126,
BRA SURGICAL BREAST SUPPORT 3XL,7950307,CDM,270,RC,,,Outpatient,,,140,112,,119,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,126,90,,,percent of total billed charges,90% of total billed charges,49,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,96.18,68.7,,,percent of total billed charges,68.7% of total billed charges,112,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,81.2,58,,,percent of total billed charges,58% of total billed charges,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,119,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,28.52,126,
BRA SURGICAL BREAST SUPPORT SMALL,7950318,CDM,270,RC,,,Outpatient,,,140,112,,119,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,126,90,,,percent of total billed charges,90% of total billed charges,49,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,96.18,68.7,,,percent of total billed charges,68.7% of total billed charges,112,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,81.2,58,,,percent of total billed charges,58% of total billed charges,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,119,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,28.52,126,
BRA SURGICAL BREAST SUPPORT MEDIUM,7950319,CDM,270,RC,,,Outpatient,,,140,112,,119,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,79.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,126,90,,,percent of total billed charges,90% of total billed charges,49,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,96.18,68.7,,,percent of total billed charges,68.7% of total billed charges,112,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,81.2,58,,,percent of total billed charges,58% of total billed charges,28.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,119,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,28.52,126,
NF-NACL 0.9% 50ML MINIBAG + (ERROR IN #),260037,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
A common prenatal test used to check on a baby's health.,405065,CDM,720,RC,59025,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,153.03,100,,,fee schedule,Pays 100% Medicare OPPS,153.03,100,,,fee schedule,Pays 100% Medicare OPPS,153.03,100,,,fee schedule,Pays 100% Medicare OPPS,203.67,130,,,fee schedule,Pays 130% Medicare OPPS,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,156.09,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,153.03,100,,,fee schedule,Pays 100% Medicare OPPS,137.72,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,156.68,100,,,fee schedule,Pays 100% Medicare OPPS,203.67,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,153.03,100,,,fee schedule,Pays 100% Medicare OPPS,29.54,203.67,
K-WIRE,1570354,CDM,278,RC,C1713,HCPCS,Both,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
SUTURE 4-0 ETHILON 1854G,1570567,CDM,272,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
SUTURE 2-0 VLOC 90 GS-21 12,1570627,CDM,272,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
DRESSING SURGICAL AQUACEL AG 3.5 X 10,1570803,CDM,272,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
NACL 0.9% 50ML MINIBAG PLUS,2600037,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
D5W 0.2% NS 1000ML,2600077,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
SOD CHLORIDE 0.9% MINIBAG PLUS 100ML,2600086,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
SOD CHLORIDE 0.9% MINIBAG PLUS 50ML,2600088,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
ACTIDOSE(CHARCOAL) W/SORBITOL 50GM/240ML,2600801,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
BACTRIM (SMP/TMP) INJ 10ML,2601017,CDM,250,RC,S0039,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
CIPRO (CIPROFLOXACIN) 200MG IV PREMIX,2601027,CDM,250,RC,J0744,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
TETANUS DIPHTHERIA INJ 0.5ML,2601048,CDM,636,RC,90714,HCPCS,Both,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.72,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,35.06,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,33.72,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.72,130.5,
SOLU-MEDROL (METHYLPREDNIS) INJ 125MG,2601294,CDM,636,RC,J2930,HCPCS,Both,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,6.91,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,7.19,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,6.91,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.91,130.5,
DOPAMINE IV 400MG/D5W 250ML,2601306,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
"HEPARIN 25,000U/D5W 500ML",2601307,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
LIDOCAINE 2GM/500ML IV PREMIX DRIP,2601354,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
NITROGLYCERIN DRIP 50MG/250ML,2601367,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
MAG SULFATE (40GM/L) 1000ML,2601370,CDM,250,RC,J3475,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,0.91,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,0.95,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,0.91,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.91,130.5,
LR 1000ML / PITOCIN 20 UNITS PREMIX,2601374,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
SOLU-MEDROL (METHYLPREDNIS) INJ 500MG,2601406,CDM,636,RC,J2930,HCPCS,Both,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,6.91,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,7.19,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,6.91,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.91,130.5,
FLAGYL (METRONIDAZOLE) 500MG IVPB,2602314,CDM,250,RC,S0030,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
HALDOL (HALOPERIDOL DECANOATE) INJ 100MG,2602649,CDM,636,RC,,,Both,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
MANNITOL 20% IVPB 250ML,2602700,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
ACTEYLCYSTEINE INJ 200MG/ML 30ML VIAL,2605016,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
KCL 20MEQ IN SW MINIBAG IV 20MEQ PREMIX,2605171,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
NACL 0.9% / KCL 40MEQ 1000ML,2605172,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
D5W/0.9% NS/KCL 40 MEQ IV SOLN 1000ML,2605173,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
D5W/0.45% NS KCL 40MEQ IV SOLN 1000ML,2610002,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
NACL 0.9% / KCL 20MEQ 1000ML,2610003,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
D5W/KCL 20 MEQ IV SOLN 1000ML,2610006,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
D5W/0.45% NS KCL 20MEQ IV SOLN 1000ML,2610009,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
D5W IV SOLN 1000ML,2610010,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
DEXTROSE 5% IV 500ML,2610011,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
DEXTROSE 5% IV 250ML,2610012,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
DEXTROSE 5% IV 100ML,2610013,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
D5W/0.45% NS IV SOLN 1000ML,2610015,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
D5W/0.9% SODIUM CHLORIDE IV SOLN 1000ML,2610020,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
LR IV SOLN 1000ML,2610022,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
NACL 0.45% 1000ML IV SOL,2610024,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
NACL 0.9% IV SOLN 1000ML,2610025,CDM,258,RC,J7030,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.24,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,3.37,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,3.24,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.24,130.5,
SODIUM CHLORIDE 0.9% IV SOLN 500ML,2610026,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
SOD CHLORIDE 0.9% IV SOLN 250ML,2610027,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
D5W/LACTATED RINGERS IV SOLN 1000ML,2610028,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
IV NITRO PUMP SET MIS,2610029,CDM,270,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
NACL 0.9% IVPB 100ML,2610030,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
NACL 0.9% 50ML IVPB,2610031,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
SODIUM CHLORIDE 0.45% IV SOLN 500ML,2610032,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
DEXTROSE 10% 500ML,2610035,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
D5W/0.45% NS KCL 10MEQ IV SOLN 1000ML,2610041,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
D5W/0.9% NS/KCL 20 MEQ IV SOLN 1000ML,2610044,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
NF-D5W/LACT RINGERS/KCL 20 MEQ 1000ML,2610046,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
NF-D5W/LACT RINGERS/KCL 40 MEQ 1000ML,2610047,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
NF-SOD CHLORIDE 0.22% IV SOLN 1000ML,2610049,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
IV PED EXTENSION MIS,2610055,CDM,270,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
IV VENTED ADAPTER MIS,2610057,CDM,270,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
IV FILTER EXT .22MIC MIS,2610058,CDM,270,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
IV BURETROL (IV VOLUMETRIC SET) MIS,2610059,CDM,270,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
SODIUM CHLORIDE 0.9% IRRIGATION 1000ML,2610062,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
IV SET SYRINGE PUMP MIS,2610069,CDM,270,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
IV SET ANESTHESIA MIS,2610070,CDM,270,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
NACL 0.45% / KCL 20MEQ 1000ML,2610071,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
SODIUM CHLORIDE 0.9% IRRIGATION 500ML,2610505,CDM,270,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
IV SECONDARY LONG MIS0,2610507,CDM,270,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
IV PRIMARY SET GRAVITY MIS,2610508,CDM,270,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
IV SECONDARY SET MIS,2610509,CDM,270,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
IV PUMP SET MIS,2610516,CDM,270,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
IV PROTECTED NEEDLE MIS,2610517,CDM,270,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
IV RATE FLOW MIS,2610521,CDM,270,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
KANGAROO (NUTRITION PUMP SET) MIS,2610536,CDM,270,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
IV EXTENSION (IV MEDLOCK W/EXT) MIS,2610540,CDM,270,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
D5W 0.2% NS W/KCL 20MEQ 1000ML,2611003,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
D5W/0.2% SOD CL IV SOLN 250ML,2611004,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
SOD CHLORIDE 3% IV SOLN 500ML,2612000,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
SODIUM CHLORIDE 0.9% IRRIGATION 3000ML,2660006,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
STERILE WATER IRRIGATION 1000 ML,2660007,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
STERILE WATER IRRIGATION 500 ML,2660008,CDM,250,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
ADENOSINE HEPLOCK,2662940,CDM,270,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
RX INTERVENTION MIS,2699991,CDM,270,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
RX MONITOR MIS,2699992,CDM,270,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
CARDIAC (ROUTINE MU ORDERS) MIS,2699998,CDM,270,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
".CYTOGENETICS, INTERP/REPO",3000106,CDM,311,RC,88291,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,30.56,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,31.78,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,30.56,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,30.56,130.5,
Test of glucose level in the blood,3000127,CDM,301,RC,82950,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,4.75,100,,,fee schedule,Pays 100% Medicare OPPS,4.75,100,,,fee schedule,Pays 100% Medicare OPPS,4.75,100,,,fee schedule,Pays 100% Medicare OPPS,6.17,130,,,fee schedule,Pays 130% Medicare OPPS,7.2,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.84,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,7.49,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,4.75,100,,,fee schedule,Pays 100% Medicare OPPS,4.27,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,7.2,120.37,,,fee schedule,120.37% of custom fee schedule,4.75,100,,,fee schedule,Pays 100% Medicare OPPS,6.17,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,4.75,100,,,fee schedule,Pays 100% Medicare OPPS,4.27,130.5,
GLUCOSE CSF,3000132,CDM,301,RC,82945,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,3.93,100,,,fee schedule,Pays 100% Medicare OPPS,3.93,100,,,fee schedule,Pays 100% Medicare OPPS,3.93,100,,,fee schedule,Pays 100% Medicare OPPS,5.1,130,,,fee schedule,Pays 130% Medicare OPPS,5.93,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,6.17,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,3.93,100,,,fee schedule,Pays 100% Medicare OPPS,3.53,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,5.93,120.37,,,fee schedule,120.37% of custom fee schedule,3.93,100,,,fee schedule,Pays 100% Medicare OPPS,5.1,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,3.93,100,,,fee schedule,Pays 100% Medicare OPPS,3.53,130.5,
"3RD REDUCING SUBSTANCES,STOOL",3000254,CDM,301,RC,84999,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,36.25,100,,,fee schedule,Pays 100% Medicare OPPS,36.25,100,,,fee schedule,Pays 100% Medicare OPPS,36.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
A lab test used to detect bacteria or fungi in a sample taken from the site of a suspected infection,3000558,CDM,306,RC,87205,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,5.55,130,,,fee schedule,Pays 130% Medicare OPPS,3.55,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.35,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,3.69,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,3.84,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,3.55,120.37,,,fee schedule,120.37% of custom fee schedule,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,5.55,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,3.55,130.5,
PROTEIN S ANTIGEN FREE,3000648,CDM,305,RC,85306,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,15.32,100,,,fee schedule,Pays 100% Medicare OPPS,15.32,100,,,fee schedule,Pays 100% Medicare OPPS,15.32,100,,,fee schedule,Pays 100% Medicare OPPS,19.91,130,,,fee schedule,Pays 130% Medicare OPPS,23.2,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.62,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,24.12,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,15.32,100,,,fee schedule,Pays 100% Medicare OPPS,13.78,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,23.2,120.37,,,fee schedule,120.37% of custom fee schedule,15.32,100,,,fee schedule,Pays 100% Medicare OPPS,19.91,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,15.32,100,,,fee schedule,Pays 100% Medicare OPPS,13.78,130.5,
Quantitative measure of glucose build up in the blood over time,3000675,CDM,301,RC,82947,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,3.93,100,,,fee schedule,Pays 100% Medicare OPPS,3.93,100,,,fee schedule,Pays 100% Medicare OPPS,3.93,100,,,fee schedule,Pays 100% Medicare OPPS,5.1,130,,,fee schedule,Pays 130% Medicare OPPS,5.93,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,6.17,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,3.93,100,,,fee schedule,Pays 100% Medicare OPPS,3.53,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,5.93,120.37,,,fee schedule,120.37% of custom fee schedule,3.93,100,,,fee schedule,Pays 100% Medicare OPPS,5.1,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,3.93,100,,,fee schedule,Pays 100% Medicare OPPS,3.53,130.5,
I-STAT SODIUM,3000676,CDM,301,RC,84295,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,4.8,100,,,fee schedule,Pays 100% Medicare OPPS,4.8,100,,,fee schedule,Pays 100% Medicare OPPS,4.8,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,130,,,fee schedule,Pays 130% Medicare OPPS,7.28,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.9,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,7.57,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,4.8,100,,,fee schedule,Pays 100% Medicare OPPS,4.32,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,7.28,120.37,,,fee schedule,120.37% of custom fee schedule,4.8,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,4.8,100,,,fee schedule,Pays 100% Medicare OPPS,4.32,130.5,
I-STAT POTASSIUM,3000677,CDM,301,RC,84132,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,4.76,100,,,fee schedule,Pays 100% Medicare OPPS,4.76,100,,,fee schedule,Pays 100% Medicare OPPS,4.76,100,,,fee schedule,Pays 100% Medicare OPPS,6.18,130,,,fee schedule,Pays 130% Medicare OPPS,6.96,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.85,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,7.24,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,4.76,100,,,fee schedule,Pays 100% Medicare OPPS,4.28,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,6.96,120.37,,,fee schedule,120.37% of custom fee schedule,4.76,100,,,fee schedule,Pays 100% Medicare OPPS,6.18,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,4.76,100,,,fee schedule,Pays 100% Medicare OPPS,4.28,130.5,
I-STAT CHLORIDE,3000678,CDM,301,RC,82435,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,4.59,100,,,fee schedule,Pays 100% Medicare OPPS,4.59,100,,,fee schedule,Pays 100% Medicare OPPS,4.59,100,,,fee schedule,Pays 100% Medicare OPPS,5.98,130,,,fee schedule,Pays 130% Medicare OPPS,6.96,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.69,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,7.24,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,4.59,100,,,fee schedule,Pays 100% Medicare OPPS,4.13,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,6.96,120.37,,,fee schedule,120.37% of custom fee schedule,4.59,100,,,fee schedule,Pays 100% Medicare OPPS,5.98,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,4.59,100,,,fee schedule,Pays 100% Medicare OPPS,4.13,130.5,
A test of the stool to diagnose Clostridium difficile (C. diff) infection,3000684,CDM,300,RC,87324,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,15.57,130,,,fee schedule,Pays 130% Medicare OPPS,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.21,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,18.88,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,10.78,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,15.57,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,10.78,130.5,
.C DIFF ANTIGEN,3000685,CDM,300,RC,87449,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,15.57,130,,,fee schedule,Pays 130% Medicare OPPS,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.21,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,18.88,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,10.78,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,15.57,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,10.78,130.5,
3RD COBALT BLOOD LEVEL,3000697,CDM,301,RC,83018,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,21.96,100,,,fee schedule,Pays 100% Medicare OPPS,21.96,100,,,fee schedule,Pays 100% Medicare OPPS,21.96,100,,,fee schedule,Pays 100% Medicare OPPS,28.54,130,,,fee schedule,Pays 130% Medicare OPPS,33.23,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.39,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,34.56,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,21.96,100,,,fee schedule,Pays 100% Medicare OPPS,19.76,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,33.23,120.37,,,fee schedule,120.37% of custom fee schedule,21.96,100,,,fee schedule,Pays 100% Medicare OPPS,28.54,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,21.96,100,,,fee schedule,Pays 100% Medicare OPPS,19.76,130.5,
CHLORIDE URINE 24 HR,3000706,CDM,301,RC,82436,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,5.75,100,,,fee schedule,Pays 100% Medicare OPPS,5.75,100,,,fee schedule,Pays 100% Medicare OPPS,5.75,100,,,fee schedule,Pays 100% Medicare OPPS,7.47,130,,,fee schedule,Pays 130% Medicare OPPS,7.61,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.86,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,7.91,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,5.75,100,,,fee schedule,Pays 100% Medicare OPPS,5.17,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,7.61,120.37,,,fee schedule,120.37% of custom fee schedule,5.75,100,,,fee schedule,Pays 100% Medicare OPPS,7.47,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,5.75,100,,,fee schedule,Pays 100% Medicare OPPS,5.17,130.5,
3RD .B-HYDROXYBUTYRATE SERUM,3082010,CDM,301,RC,82010,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,8.17,100,,,fee schedule,Pays 100% Medicare OPPS,8.17,100,,,fee schedule,Pays 100% Medicare OPPS,8.17,100,,,fee schedule,Pays 100% Medicare OPPS,10.62,130,,,fee schedule,Pays 130% Medicare OPPS,12.37,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.33,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,12.87,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,8.17,100,,,fee schedule,Pays 100% Medicare OPPS,7.35,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,12.37,120.37,,,fee schedule,120.37% of custom fee schedule,8.17,100,,,fee schedule,Pays 100% Medicare OPPS,10.62,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,8.17,100,,,fee schedule,Pays 100% Medicare OPPS,7.35,130.5,
"ALBUMIN, SERUM",3082040,CDM,301,RC,82040,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,4.95,100,,,fee schedule,Pays 100% Medicare OPPS,4.95,100,,,fee schedule,Pays 100% Medicare OPPS,4.95,100,,,fee schedule,Pays 100% Medicare OPPS,6.43,130,,,fee schedule,Pays 130% Medicare OPPS,4.36,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.04,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,4.53,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,4.95,100,,,fee schedule,Pays 100% Medicare OPPS,4.45,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,4.36,120.37,,,fee schedule,120.37% of custom fee schedule,4.95,100,,,fee schedule,Pays 100% Medicare OPPS,6.43,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,4.95,100,,,fee schedule,Pays 100% Medicare OPPS,4.36,130.5,
"ALBUMIN, other",3082042,CDM,301,RC,82042,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,7.78,100,,,fee schedule,Pays 100% Medicare OPPS,7.78,100,,,fee schedule,Pays 100% Medicare OPPS,7.78,100,,,fee schedule,Pays 100% Medicare OPPS,10.11,130,,,fee schedule,Pays 130% Medicare OPPS,7.84,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,7.93,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,8.15,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,7.78,100,,,fee schedule,Pays 100% Medicare OPPS,7,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,7.84,120.37,,,fee schedule,120.37% of custom fee schedule,7.78,100,,,fee schedule,Pays 100% Medicare OPPS,10.11,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,7.78,100,,,fee schedule,Pays 100% Medicare OPPS,7,130.5,
MATERNAL SCREEN 1,3082105,CDM,300,RC,82105,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,16.77,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,100,,,fee schedule,Pays 100% Medicare OPPS,21.8,130,,,fee schedule,Pays 130% Medicare OPPS,25.4,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.1,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,26.41,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,16.77,100,,,fee schedule,Pays 100% Medicare OPPS,15.09,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,25.4,120.37,,,fee schedule,120.37% of custom fee schedule,16.77,100,,,fee schedule,Pays 100% Medicare OPPS,21.8,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,16.77,100,,,fee schedule,Pays 100% Medicare OPPS,15.09,130.5,
CHLORIDE SERUM,3082435,CDM,301,RC,82435,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,4.59,100,,,fee schedule,Pays 100% Medicare OPPS,4.59,100,,,fee schedule,Pays 100% Medicare OPPS,4.59,100,,,fee schedule,Pays 100% Medicare OPPS,5.98,130,,,fee schedule,Pays 130% Medicare OPPS,6.96,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.69,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,7.24,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,4.59,100,,,fee schedule,Pays 100% Medicare OPPS,4.13,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,6.96,120.37,,,fee schedule,120.37% of custom fee schedule,4.59,100,,,fee schedule,Pays 100% Medicare OPPS,5.98,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,4.59,100,,,fee schedule,Pays 100% Medicare OPPS,4.13,130.5,
CHLORIDE URINE SPOT,3082436,CDM,301,RC,82436,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,5.75,100,,,fee schedule,Pays 100% Medicare OPPS,5.75,100,,,fee schedule,Pays 100% Medicare OPPS,5.75,100,,,fee schedule,Pays 100% Medicare OPPS,7.47,130,,,fee schedule,Pays 130% Medicare OPPS,7.61,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.86,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,7.91,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,5.75,100,,,fee schedule,Pays 100% Medicare OPPS,5.17,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,7.61,120.37,,,fee schedule,120.37% of custom fee schedule,5.75,100,,,fee schedule,Pays 100% Medicare OPPS,7.47,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,5.75,100,,,fee schedule,Pays 100% Medicare OPPS,5.17,130.5,
CHLORIDE BODY FLUID,3082438,CDM,301,RC,82438,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,5,100,,,fee schedule,Pays 100% Medicare OPPS,6.5,130,,,fee schedule,Pays 130% Medicare OPPS,7.4,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.1,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,7.7,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,4.5,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,7.4,120.37,,,fee schedule,120.37% of custom fee schedule,5,100,,,fee schedule,Pays 100% Medicare OPPS,6.5,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,5,100,,,fee schedule,Pays 100% Medicare OPPS,4.5,130.5,
3RD GLUCOSE BODY FLUID,3082945,CDM,301,RC,82945,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,3.93,100,,,fee schedule,Pays 100% Medicare OPPS,3.93,100,,,fee schedule,Pays 100% Medicare OPPS,3.93,100,,,fee schedule,Pays 100% Medicare OPPS,5.1,130,,,fee schedule,Pays 130% Medicare OPPS,5.93,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,6.17,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,3.93,100,,,fee schedule,Pays 100% Medicare OPPS,3.53,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,5.93,120.37,,,fee schedule,120.37% of custom fee schedule,3.93,100,,,fee schedule,Pays 100% Medicare OPPS,5.1,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,3.93,100,,,fee schedule,Pays 100% Medicare OPPS,3.53,130.5,
Quantitative measure of glucose build up in the blood over time,3082947,CDM,301,RC,82947,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,3.93,100,,,fee schedule,Pays 100% Medicare OPPS,3.93,100,,,fee schedule,Pays 100% Medicare OPPS,3.93,100,,,fee schedule,Pays 100% Medicare OPPS,5.1,130,,,fee schedule,Pays 130% Medicare OPPS,5.93,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,6.17,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,3.93,100,,,fee schedule,Pays 100% Medicare OPPS,3.53,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,5.93,120.37,,,fee schedule,120.37% of custom fee schedule,3.93,100,,,fee schedule,Pays 100% Medicare OPPS,5.1,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,3.93,100,,,fee schedule,Pays 100% Medicare OPPS,3.53,130.5,
Test of glucose level in the blood,3082950,CDM,301,RC,82950,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,4.75,100,,,fee schedule,Pays 100% Medicare OPPS,4.75,100,,,fee schedule,Pays 100% Medicare OPPS,4.75,100,,,fee schedule,Pays 100% Medicare OPPS,6.17,130,,,fee schedule,Pays 130% Medicare OPPS,7.2,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.84,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,7.49,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,4.75,100,,,fee schedule,Pays 100% Medicare OPPS,4.27,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,7.2,120.37,,,fee schedule,120.37% of custom fee schedule,4.75,100,,,fee schedule,Pays 100% Medicare OPPS,6.17,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,4.75,100,,,fee schedule,Pays 100% Medicare OPPS,4.27,130.5,
.GTT ADDITIONAL,3082952,CDM,301,RC,82952,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,3.92,100,,,fee schedule,Pays 100% Medicare OPPS,3.92,100,,,fee schedule,Pays 100% Medicare OPPS,3.92,100,,,fee schedule,Pays 100% Medicare OPPS,5.09,130,,,fee schedule,Pays 130% Medicare OPPS,5.93,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3.99,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,6.17,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,3.92,100,,,fee schedule,Pays 100% Medicare OPPS,3.52,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,5.93,120.37,,,fee schedule,120.37% of custom fee schedule,3.92,100,,,fee schedule,Pays 100% Medicare OPPS,5.09,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,3.92,100,,,fee schedule,Pays 100% Medicare OPPS,3.52,130.5,
Test of breath for a stomach bacterium,3083013,CDM,301,RC,83013,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,67.36,100,,,fee schedule,Pays 100% Medicare OPPS,67.36,100,,,fee schedule,Pays 100% Medicare OPPS,67.36,100,,,fee schedule,Pays 100% Medicare OPPS,87.56,130,,,fee schedule,Pays 130% Medicare OPPS,80.08,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,68.7,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,83.28,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,67.36,100,,,fee schedule,Pays 100% Medicare OPPS,60.62,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,80.08,120.37,,,fee schedule,120.37% of custom fee schedule,67.36,100,,,fee schedule,Pays 100% Medicare OPPS,87.56,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,67.36,100,,,fee schedule,Pays 100% Medicare OPPS,60.62,130.5,
DIRECT LDL,3083721,CDM,301,RC,83721,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,10.5,100,,,fee schedule,Pays 100% Medicare OPPS,10.5,100,,,fee schedule,Pays 100% Medicare OPPS,10.5,100,,,fee schedule,Pays 100% Medicare OPPS,13.65,130,,,fee schedule,Pays 130% Medicare OPPS,14.44,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,10.71,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,15.02,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,10.5,100,,,fee schedule,Pays 100% Medicare OPPS,9.45,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,14.44,120.37,,,fee schedule,120.37% of custom fee schedule,10.5,100,,,fee schedule,Pays 100% Medicare OPPS,13.65,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,10.5,100,,,fee schedule,Pays 100% Medicare OPPS,9.45,130.5,
POTASSIUM SERUM,3084132,CDM,301,RC,84132,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,4.76,100,,,fee schedule,Pays 100% Medicare OPPS,4.76,100,,,fee schedule,Pays 100% Medicare OPPS,4.76,100,,,fee schedule,Pays 100% Medicare OPPS,6.18,130,,,fee schedule,Pays 130% Medicare OPPS,6.96,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.85,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,7.24,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,4.76,100,,,fee schedule,Pays 100% Medicare OPPS,4.28,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,6.96,120.37,,,fee schedule,120.37% of custom fee schedule,4.76,100,,,fee schedule,Pays 100% Medicare OPPS,6.18,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,4.76,100,,,fee schedule,Pays 100% Medicare OPPS,4.28,130.5,
POTASSIUM URINE SPOT,3084133,CDM,301,RC,84133,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,4.73,100,,,fee schedule,Pays 100% Medicare OPPS,4.73,100,,,fee schedule,Pays 100% Medicare OPPS,4.73,100,,,fee schedule,Pays 100% Medicare OPPS,6.14,130,,,fee schedule,Pays 130% Medicare OPPS,6.51,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.82,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,6.77,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,4.73,100,,,fee schedule,Pays 100% Medicare OPPS,4.25,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,6.51,120.37,,,fee schedule,120.37% of custom fee schedule,4.73,100,,,fee schedule,Pays 100% Medicare OPPS,6.14,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,4.73,100,,,fee schedule,Pays 100% Medicare OPPS,4.25,130.5,
SELENIUM LEVEL,3084255,CDM,301,RC,84255,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,25.53,100,,,fee schedule,Pays 100% Medicare OPPS,25.53,100,,,fee schedule,Pays 100% Medicare OPPS,25.53,100,,,fee schedule,Pays 100% Medicare OPPS,33.18,130,,,fee schedule,Pays 130% Medicare OPPS,38.64,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,26.04,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,40.18,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,25.53,100,,,fee schedule,Pays 100% Medicare OPPS,22.97,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,38.64,120.37,,,fee schedule,120.37% of custom fee schedule,25.53,100,,,fee schedule,Pays 100% Medicare OPPS,33.18,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,25.53,100,,,fee schedule,Pays 100% Medicare OPPS,22.97,130.5,
SODIUM SERUM,3084295,CDM,301,RC,84295,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,4.8,100,,,fee schedule,Pays 100% Medicare OPPS,4.8,100,,,fee schedule,Pays 100% Medicare OPPS,4.8,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,130,,,fee schedule,Pays 130% Medicare OPPS,7.28,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.9,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,7.57,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,4.8,100,,,fee schedule,Pays 100% Medicare OPPS,4.32,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,7.28,120.37,,,fee schedule,120.37% of custom fee schedule,4.8,100,,,fee schedule,Pays 100% Medicare OPPS,6.25,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,4.8,100,,,fee schedule,Pays 100% Medicare OPPS,4.32,130.5,
SODIUM URINE SPOT,3084300,CDM,301,RC,84300,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,5.05,100,,,fee schedule,Pays 100% Medicare OPPS,5.05,100,,,fee schedule,Pays 100% Medicare OPPS,5.05,100,,,fee schedule,Pays 100% Medicare OPPS,6.57,130,,,fee schedule,Pays 130% Medicare OPPS,5.24,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.16,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,5.45,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,5.05,100,,,fee schedule,Pays 100% Medicare OPPS,4.55,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,5.24,120.37,,,fee schedule,120.37% of custom fee schedule,5.05,100,,,fee schedule,Pays 100% Medicare OPPS,6.57,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,5.05,100,,,fee schedule,Pays 100% Medicare OPPS,4.55,130.5,
SODIUM FECES,3084302,CDM,301,RC,84302,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,4.86,100,,,fee schedule,Pays 100% Medicare OPPS,4.86,100,,,fee schedule,Pays 100% Medicare OPPS,4.86,100,,,fee schedule,Pays 100% Medicare OPPS,6.31,130,,,fee schedule,Pays 130% Medicare OPPS,5.24,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.95,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,5.45,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,4.86,100,,,fee schedule,Pays 100% Medicare OPPS,4.37,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,5.24,120.37,,,fee schedule,120.37% of custom fee schedule,4.86,100,,,fee schedule,Pays 100% Medicare OPPS,6.31,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,4.86,100,,,fee schedule,Pays 100% Medicare OPPS,4.37,130.5,
Blood test to screen for syphilis,3086592,CDM,302,RC,86592,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,5.55,130,,,fee schedule,Pays 130% Medicare OPPS,5.6,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.35,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,5.82,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,3.84,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,5.6,120.37,,,fee schedule,120.37% of custom fee schedule,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,5.55,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,3.84,130.5,
EBV EARLY AG IGG(EB VIRUS),3086663,CDM,302,RC,86663,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,13.12,100,,,fee schedule,Pays 100% Medicare OPPS,13.12,100,,,fee schedule,Pays 100% Medicare OPPS,13.12,100,,,fee schedule,Pays 100% Medicare OPPS,17.05,130,,,fee schedule,Pays 130% Medicare OPPS,19.86,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.38,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,20.65,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,13.12,100,,,fee schedule,Pays 100% Medicare OPPS,11.8,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,19.86,120.37,,,fee schedule,120.37% of custom fee schedule,13.12,100,,,fee schedule,Pays 100% Medicare OPPS,17.05,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,13.12,100,,,fee schedule,Pays 100% Medicare OPPS,11.8,130.5,
A lab test used to detect bacteria or fungi in a sample taken from the site of a suspected infection,3087205,CDM,306,RC,87205,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,5.55,130,,,fee schedule,Pays 130% Medicare OPPS,3.55,120.37,,,fee schedule,120.37% of custom fee schedule,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.35,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,3.69,125.18,,,fee schedule,125.18% of custom fee schedule,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,3.84,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,3.55,120.37,,,fee schedule,120.37% of custom fee schedule,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,5.55,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,3.55,130.5,
PT REGULAR VISIT,5000001,CDM,424,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
OT REGULAR VISIT,5100001,CDM,430,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
OT WHIRLPOOL (PER SESSION),5197022,CDM,430,RC,97022,HCPCS,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,16.22,100,,,fee schedule,Pays 100% Medicare OPPS,16.22,100,,,fee schedule,Pays 100% Medicare OPPS,16.22,100,,,fee schedule,Pays 100% Medicare OPPS,20.74,130,,,fee schedule,Pays 130% Medicare OPPS,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.54,102,,,fee schedule,Pays 102% Medicare OPPS,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,16.22,100,,,fee schedule,Pays 100% Medicare OPPS,14.6,90,,,fee schedule,Pays 90% Medicare OPPS,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,15.95,100,,,fee schedule,Pays 100% Medicare OPPS,20.74,130,,,fee schedule,Pays 130% Medicare OPPS,123.25,85,,,percent of total billed charges,85% of total billed charges,16.22,100,,,fee schedule,Pays 100% Medicare OPPS,14.6,130.5,
SUTURE TRAY,7905862,CDM,272,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
SUTURE ENDOLOOP EZ10G,7950239,CDM,272,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
NEEDLE BIOPSY TRU-CUT 14 GA. X 4.5,7950248,CDM,270,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
TROCAR X-CEL 5MM B5LT,7950259,CDM,270,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
TROCAR XCEL BLUNT TIP H12LP,7950263,CDM,270,RC,,,Outpatient,,,145,116,,123.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,130.5,90,,,percent of total billed charges,90% of total billed charges,50.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,99.62,68.7,,,percent of total billed charges,68.7% of total billed charges,116,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,84.1,58,,,percent of total billed charges,58% of total billed charges,29.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,123.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,29.54,130.5,
DEB SUBQ TISSUE ADDON ADDL 20 SQ CM,1511045,CDM,360,RC,11045,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,,,,,other,Not reimbursable per contract,135,90,,,percent of total billed charges,90% of total billed charges,52.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,87,58,,,percent of total billed charges,58% of total billed charges,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,127.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,30.56,986.63,
OBSERVATION 1ST HR,2099219,CDM,762,RC,99219,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,135,90,,,percent of total billed charges,90% of total billed charges,52.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,87,58,,,percent of total billed charges,58% of total billed charges,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,127.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,30.56,135,
DELESTROGEN (ESTRADIOL VAL) INJ : 20MG,2605166,CDM,636,RC,J1380,HCPCS,Both,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,135,90,,,percent of total billed charges,90% of total billed charges,52.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,87,58,,,percent of total billed charges,58% of total billed charges,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,127.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,30.56,135,
CALCIUM URINE SPOT,3000037,CDM,301,RC,82310,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,5.16,100,,,fee schedule,Pays 100% Medicare OPPS,5.16,100,,,fee schedule,Pays 100% Medicare OPPS,5.16,100,,,fee schedule,Pays 100% Medicare OPPS,6.7,130,,,fee schedule,Pays 130% Medicare OPPS,7.64,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.26,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,7.95,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,5.16,100,,,fee schedule,Pays 100% Medicare OPPS,4.64,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,7.64,120.37,,,fee schedule,120.37% of custom fee schedule,5.16,100,,,fee schedule,Pays 100% Medicare OPPS,6.7,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,5.16,100,,,fee schedule,Pays 100% Medicare OPPS,4.64,135,
CHLAMYDIA TRACHOMATIS IGG ABS,3000045,CDM,302,RC,86631,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,11.82,100,,,fee schedule,Pays 100% Medicare OPPS,11.82,100,,,fee schedule,Pays 100% Medicare OPPS,11.82,100,,,fee schedule,Pays 100% Medicare OPPS,15.36,130,,,fee schedule,Pays 130% Medicare OPPS,17.9,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.05,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,18.61,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,11.82,100,,,fee schedule,Pays 100% Medicare OPPS,10.63,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,17.9,120.37,,,fee schedule,120.37% of custom fee schedule,11.82,100,,,fee schedule,Pays 100% Medicare OPPS,15.36,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,11.82,100,,,fee schedule,Pays 100% Medicare OPPS,10.63,135,
CHLAMYDIA TRACHOMATIS IGM ABS,3000046,CDM,302,RC,86632,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,12.68,100,,,fee schedule,Pays 100% Medicare OPPS,12.68,100,,,fee schedule,Pays 100% Medicare OPPS,12.68,100,,,fee schedule,Pays 100% Medicare OPPS,16.48,130,,,fee schedule,Pays 130% Medicare OPPS,19.22,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.93,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,19.99,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,12.68,100,,,fee schedule,Pays 100% Medicare OPPS,11.41,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,19.22,120.37,,,fee schedule,120.37% of custom fee schedule,12.68,100,,,fee schedule,Pays 100% Medicare OPPS,16.48,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,12.68,100,,,fee schedule,Pays 100% Medicare OPPS,11.41,135,
Test to measure creatinine in the urine,3000061,CDM,301,RC,82570,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,6.73,130,,,fee schedule,Pays 130% Medicare OPPS,7.84,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.28,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,8.15,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,4.66,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,7.84,120.37,,,fee schedule,120.37% of custom fee schedule,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,6.73,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,4.66,135,
.CYCLOSPORA CONCENTRATION,3000076,CDM,300,RC,87015,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,6.68,100,,,fee schedule,Pays 100% Medicare OPPS,6.68,100,,,fee schedule,Pays 100% Medicare OPPS,6.68,100,,,fee schedule,Pays 100% Medicare OPPS,8.68,130,,,fee schedule,Pays 130% Medicare OPPS,10.11,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.81,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,10.52,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,6.68,100,,,fee schedule,Pays 100% Medicare OPPS,6.01,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,10.11,120.37,,,fee schedule,120.37% of custom fee schedule,6.68,100,,,fee schedule,Pays 100% Medicare OPPS,8.68,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,6.68,100,,,fee schedule,Pays 100% Medicare OPPS,6.01,135,
EOSIN COUNT URINE,3000101,CDM,300,RC,85999,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,135,90,,,percent of total billed charges,90% of total billed charges,52.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,87,58,,,percent of total billed charges,58% of total billed charges,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,127.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,30.56,135,
".FLOW CYTOMETRY, EA MARKER",3000113,CDM,300,RC,88182,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,57.33,130,,,fee schedule,Pays 130% Medicare OPPS,80.6,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.53,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,83.82,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,40.17,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,80.6,120.37,,,fee schedule,120.37% of custom fee schedule,44.1,100,,,fee schedule,Pays 100% Medicare OPPS,57.33,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,40.17,135,
.PARVOVIRUS PANEL IGM,3000226,CDM,302,RC,86747,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,15.03,100,,,fee schedule,Pays 100% Medicare OPPS,15.03,100,,,fee schedule,Pays 100% Medicare OPPS,15.03,100,,,fee schedule,Pays 100% Medicare OPPS,19.53,130,,,fee schedule,Pays 130% Medicare OPPS,22.75,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.33,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,23.66,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,15.03,100,,,fee schedule,Pays 100% Medicare OPPS,13.52,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,22.75,120.37,,,fee schedule,120.37% of custom fee schedule,15.03,100,,,fee schedule,Pays 100% Medicare OPPS,19.53,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,15.03,100,,,fee schedule,Pays 100% Medicare OPPS,13.52,135,
URIC ACID SYNOVIAL FLUID,3000570,CDM,301,RC,84560,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,5.08,100,,,fee schedule,Pays 100% Medicare OPPS,5.08,100,,,fee schedule,Pays 100% Medicare OPPS,5.08,100,,,fee schedule,Pays 100% Medicare OPPS,6.6,130,,,fee schedule,Pays 130% Medicare OPPS,7.2,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.18,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,7.49,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,5.08,100,,,fee schedule,Pays 100% Medicare OPPS,4.57,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,7.2,120.37,,,fee schedule,120.37% of custom fee schedule,5.08,100,,,fee schedule,Pays 100% Medicare OPPS,6.6,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,5.08,100,,,fee schedule,Pays 100% Medicare OPPS,4.57,135,
I-STAT BUN,3000679,CDM,301,RC,84520,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,3.95,100,,,fee schedule,Pays 100% Medicare OPPS,3.95,100,,,fee schedule,Pays 100% Medicare OPPS,3.95,100,,,fee schedule,Pays 100% Medicare OPPS,5.13,130,,,fee schedule,Pays 130% Medicare OPPS,5.97,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.02,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,6.21,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,3.95,100,,,fee schedule,Pays 100% Medicare OPPS,3.55,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,5.97,120.37,,,fee schedule,120.37% of custom fee schedule,3.95,100,,,fee schedule,Pays 100% Medicare OPPS,5.13,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,3.95,100,,,fee schedule,Pays 100% Medicare OPPS,3.55,135,
I-STAT IONIZED CA++,3000680,CDM,301,RC,80047,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,13.73,100,,,fee schedule,Pays 100% Medicare OPPS,13.73,100,,,fee schedule,Pays 100% Medicare OPPS,13.73,100,,,fee schedule,Pays 100% Medicare OPPS,17.84,130,,,fee schedule,Pays 130% Medicare OPPS,33.05,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,34.37,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,13.73,100,,,fee schedule,Pays 100% Medicare OPPS,12.35,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,33.05,120.37,,,fee schedule,120.37% of custom fee schedule,13.73,100,,,fee schedule,Pays 100% Medicare OPPS,17.84,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,13.73,100,,,fee schedule,Pays 100% Medicare OPPS,12.35,135,
I-STAT CREATININE,3000682,CDM,301,RC,82565,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,5.12,100,,,fee schedule,Pays 100% Medicare OPPS,5.12,100,,,fee schedule,Pays 100% Medicare OPPS,5.12,100,,,fee schedule,Pays 100% Medicare OPPS,6.65,130,,,fee schedule,Pays 130% Medicare OPPS,7.64,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.22,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,7.95,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,5.12,100,,,fee schedule,Pays 100% Medicare OPPS,4.6,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,7.64,120.37,,,fee schedule,120.37% of custom fee schedule,5.12,100,,,fee schedule,Pays 100% Medicare OPPS,6.65,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,5.12,100,,,fee schedule,Pays 100% Medicare OPPS,4.6,135,
Chemical test of the blood to measure presence or concentration of a substance in the blood,3000698,CDM,300,RC,83516,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.76,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,16.84,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,135,
Urine test to measure albumin,3000717,CDM,301,RC,82043,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,5.78,100,,,fee schedule,Pays 100% Medicare OPPS,5.78,100,,,fee schedule,Pays 100% Medicare OPPS,5.78,100,,,fee schedule,Pays 100% Medicare OPPS,7.51,130,,,fee schedule,Pays 130% Medicare OPPS,8.76,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.89,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,9.11,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,5.78,100,,,fee schedule,Pays 100% Medicare OPPS,5.2,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,8.76,120.37,,,fee schedule,120.37% of custom fee schedule,5.78,100,,,fee schedule,Pays 100% Medicare OPPS,7.51,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,5.78,100,,,fee schedule,Pays 100% Medicare OPPS,5.2,135,
.T 3 UPTAKE (EFCH),3000804,CDM,301,RC,84479,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,8.41,130,,,fee schedule,Pays 130% Medicare OPPS,9.8,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.59,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,10.19,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,5.82,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,9.8,120.37,,,fee schedule,120.37% of custom fee schedule,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,8.41,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,5.82,135,
CALCIUM SERUM,3082310,CDM,301,RC,82310,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,5.16,100,,,fee schedule,Pays 100% Medicare OPPS,5.16,100,,,fee schedule,Pays 100% Medicare OPPS,5.16,100,,,fee schedule,Pays 100% Medicare OPPS,6.7,130,,,fee schedule,Pays 130% Medicare OPPS,7.64,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.26,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,7.95,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,5.16,100,,,fee schedule,Pays 100% Medicare OPPS,4.64,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,7.64,120.37,,,fee schedule,120.37% of custom fee schedule,5.16,100,,,fee schedule,Pays 100% Medicare OPPS,6.7,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,5.16,100,,,fee schedule,Pays 100% Medicare OPPS,4.64,135,
"CREATININE, SERUM",3082565,CDM,301,RC,82565,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,5.12,100,,,fee schedule,Pays 100% Medicare OPPS,5.12,100,,,fee schedule,Pays 100% Medicare OPPS,5.12,100,,,fee schedule,Pays 100% Medicare OPPS,6.65,130,,,fee schedule,Pays 130% Medicare OPPS,7.64,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.22,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,7.95,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,5.12,100,,,fee schedule,Pays 100% Medicare OPPS,4.6,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,7.64,120.37,,,fee schedule,120.37% of custom fee schedule,5.12,100,,,fee schedule,Pays 100% Medicare OPPS,6.65,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,5.12,100,,,fee schedule,Pays 100% Medicare OPPS,4.6,135,
CYSTATIN C,3082610,CDM,301,RC,82610,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,18.52,100,,,fee schedule,Pays 100% Medicare OPPS,18.52,100,,,fee schedule,Pays 100% Medicare OPPS,18.52,100,,,fee schedule,Pays 100% Medicare OPPS,24.07,130,,,fee schedule,Pays 130% Medicare OPPS,20.58,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.89,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,21.41,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,18.52,100,,,fee schedule,Pays 100% Medicare OPPS,16.66,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,20.58,120.37,,,fee schedule,120.37% of custom fee schedule,18.52,100,,,fee schedule,Pays 100% Medicare OPPS,24.07,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,18.52,100,,,fee schedule,Pays 100% Medicare OPPS,16.66,135,
ALK PHOSP,3084075,CDM,301,RC,84075,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,6.73,130,,,fee schedule,Pays 130% Medicare OPPS,7.64,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.28,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,7.95,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,4.66,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,7.64,120.37,,,fee schedule,120.37% of custom fee schedule,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,6.73,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,4.66,135,
PHOSPHORUS LEVEL,3084100,CDM,301,RC,84100,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,4.74,100,,,fee schedule,Pays 100% Medicare OPPS,4.74,100,,,fee schedule,Pays 100% Medicare OPPS,4.74,100,,,fee schedule,Pays 100% Medicare OPPS,6.16,130,,,fee schedule,Pays 130% Medicare OPPS,7.19,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.83,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,7.47,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,4.74,100,,,fee schedule,Pays 100% Medicare OPPS,4.26,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,7.19,120.37,,,fee schedule,120.37% of custom fee schedule,4.74,100,,,fee schedule,Pays 100% Medicare OPPS,6.16,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,4.74,100,,,fee schedule,Pays 100% Medicare OPPS,4.26,135,
PHOSPHORUS URINE,3084105,CDM,301,RC,84105,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,5.78,100,,,fee schedule,Pays 100% Medicare OPPS,5.78,100,,,fee schedule,Pays 100% Medicare OPPS,5.78,100,,,fee schedule,Pays 100% Medicare OPPS,7.51,130,,,fee schedule,Pays 130% Medicare OPPS,7.84,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.89,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,8.15,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,5.78,100,,,fee schedule,Pays 100% Medicare OPPS,5.2,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,7.84,120.37,,,fee schedule,120.37% of custom fee schedule,5.78,100,,,fee schedule,Pays 100% Medicare OPPS,7.51,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,5.78,100,,,fee schedule,Pays 100% Medicare OPPS,5.2,135,
PROTEIN URINE,3084156,CDM,301,RC,84156,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,3.67,100,,,fee schedule,Pays 100% Medicare OPPS,3.67,100,,,fee schedule,Pays 100% Medicare OPPS,3.67,100,,,fee schedule,Pays 100% Medicare OPPS,4.77,130,,,fee schedule,Pays 130% Medicare OPPS,5.55,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3.74,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,5.77,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,3.67,100,,,fee schedule,Pays 100% Medicare OPPS,3.3,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,5.55,120.37,,,fee schedule,120.37% of custom fee schedule,3.67,100,,,fee schedule,Pays 100% Medicare OPPS,4.77,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,3.67,100,,,fee schedule,Pays 100% Medicare OPPS,3.3,135,
T 3 UPTAKE OR T UPTAKE,3084479,CDM,301,RC,84479,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,8.41,130,,,fee schedule,Pays 130% Medicare OPPS,9.8,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.59,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,10.19,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,5.82,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,9.8,120.37,,,fee schedule,120.37% of custom fee schedule,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,8.41,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,5.82,135,
BUN SERUM,3084520,CDM,301,RC,84520,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,3.95,100,,,fee schedule,Pays 100% Medicare OPPS,3.95,100,,,fee schedule,Pays 100% Medicare OPPS,3.95,100,,,fee schedule,Pays 100% Medicare OPPS,5.13,130,,,fee schedule,Pays 130% Medicare OPPS,5.97,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.02,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,6.21,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,3.95,100,,,fee schedule,Pays 100% Medicare OPPS,3.55,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,5.97,120.37,,,fee schedule,120.37% of custom fee schedule,3.95,100,,,fee schedule,Pays 100% Medicare OPPS,5.13,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,3.95,100,,,fee schedule,Pays 100% Medicare OPPS,3.55,135,
BUN URINE,3084540,CDM,301,RC,84540,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,5.56,100,,,fee schedule,Pays 100% Medicare OPPS,5.56,100,,,fee schedule,Pays 100% Medicare OPPS,5.56,100,,,fee schedule,Pays 100% Medicare OPPS,7.22,130,,,fee schedule,Pays 130% Medicare OPPS,7.2,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.67,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,7.49,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,5.56,100,,,fee schedule,Pays 100% Medicare OPPS,5,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,7.2,120.37,,,fee schedule,120.37% of custom fee schedule,5.56,100,,,fee schedule,Pays 100% Medicare OPPS,7.22,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,5.56,100,,,fee schedule,Pays 100% Medicare OPPS,5,135,
URIC ACID URINE,3084560,CDM,301,RC,84560,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,5.08,100,,,fee schedule,Pays 100% Medicare OPPS,5.08,100,,,fee schedule,Pays 100% Medicare OPPS,5.08,100,,,fee schedule,Pays 100% Medicare OPPS,6.6,130,,,fee schedule,Pays 130% Medicare OPPS,7.2,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.18,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,7.49,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,5.08,100,,,fee schedule,Pays 100% Medicare OPPS,4.57,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,7.2,120.37,,,fee schedule,120.37% of custom fee schedule,5.08,100,,,fee schedule,Pays 100% Medicare OPPS,6.6,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,5.08,100,,,fee schedule,Pays 100% Medicare OPPS,4.57,135,
EOSIN COUNT BLOOD,3085009,CDM,305,RC,85004,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,8.41,130,,,fee schedule,Pays 130% Medicare OPPS,9.8,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.59,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,10.19,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,5.82,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,9.8,120.37,,,fee schedule,120.37% of custom fee schedule,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,8.41,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,5.82,135,
RETIC COUNT,3085045,CDM,305,RC,85045,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,3.99,100,,,fee schedule,Pays 100% Medicare OPPS,3.99,100,,,fee schedule,Pays 100% Medicare OPPS,3.99,100,,,fee schedule,Pays 100% Medicare OPPS,5.18,130,,,fee schedule,Pays 130% Medicare OPPS,6.05,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.06,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,6.3,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,3.99,100,,,fee schedule,Pays 100% Medicare OPPS,3.59,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,6.05,120.37,,,fee schedule,120.37% of custom fee schedule,3.99,100,,,fee schedule,Pays 100% Medicare OPPS,5.18,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,3.99,100,,,fee schedule,Pays 100% Medicare OPPS,3.59,135,
C REACTIVE PROTEIN (CRP),3086140,CDM,302,RC,86140,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,6.73,130,,,fee schedule,Pays 130% Medicare OPPS,7.84,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.28,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,8.15,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,4.66,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,7.84,120.37,,,fee schedule,120.37% of custom fee schedule,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,6.73,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,4.66,135,
RC RH PHENOTYPING COMPLETE,3086906,CDM,300,RC,86906,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,38.83,130,,,fee schedule,Pays 130% Medicare OPPS,11.74,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.01,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,12.21,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,27.36,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,11.74,120.37,,,fee schedule,120.37% of custom fee schedule,29.87,100,,,fee schedule,Pays 100% Medicare OPPS,38.83,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,11.74,135,
.ANTIGLOBULIN (X-M),3086922,CDM,300,RC,86922,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,179.8,130,,,fee schedule,Pays 130% Medicare OPPS,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,136.65,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,52.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,120.57,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,138.31,100,,,fee schedule,Pays 100% Medicare OPPS,179.8,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,30.56,179.8,
.CYCLOSPORA STAIN,3087207,CDM,300,RC,87207,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,5.99,100,,,fee schedule,Pays 100% Medicare OPPS,5.99,100,,,fee schedule,Pays 100% Medicare OPPS,5.99,100,,,fee schedule,Pays 100% Medicare OPPS,7.78,130,,,fee schedule,Pays 130% Medicare OPPS,9.06,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.1,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,9.43,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,5.99,100,,,fee schedule,Pays 100% Medicare OPPS,5.39,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,9.06,120.37,,,fee schedule,120.37% of custom fee schedule,5.99,100,,,fee schedule,Pays 100% Medicare OPPS,7.78,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,5.99,100,,,fee schedule,Pays 100% Medicare OPPS,5.39,135,
EOSIN SMEAR NASAL,3089190,CDM,309,RC,89190,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,5.79,100,,,fee schedule,Pays 100% Medicare OPPS,5.79,100,,,fee schedule,Pays 100% Medicare OPPS,5.79,100,,,fee schedule,Pays 100% Medicare OPPS,7.52,130,,,fee schedule,Pays 130% Medicare OPPS,7.2,120.37,,,fee schedule,120.37% of custom fee schedule,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.9,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,7.49,125.18,,,fee schedule,125.18% of custom fee schedule,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,5.79,100,,,fee schedule,Pays 100% Medicare OPPS,5.21,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,7.2,120.37,,,fee schedule,120.37% of custom fee schedule,5.79,100,,,fee schedule,Pays 100% Medicare OPPS,7.52,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,5.79,100,,,fee schedule,Pays 100% Medicare OPPS,5.21,135,
Scan to measure bone mineral density (BMD) at the spine and hip,4176077,CDM,320,RC,77080,HCPCS,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,135,90,,,percent of total billed charges,90% of total billed charges,52.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,87,58,,,percent of total billed charges,58% of total billed charges,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,127.5,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,30.56,135,
NM VENTISCAN III,4500022,CDM,270,RC,,,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,135,90,,,percent of total billed charges,90% of total billed charges,52.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,87,58,,,percent of total billed charges,58% of total billed charges,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,127.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,30.56,135,
NM COLD PYP SOLUTION,4500029,CDM,270,RC,,,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,135,90,,,percent of total billed charges,90% of total billed charges,52.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,87,58,,,percent of total billed charges,58% of total billed charges,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,127.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,30.56,135,
SPLINT POSTERIOR LEAF C7826-02,5007123,CDM,270,RC,,,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,135,90,,,percent of total billed charges,90% of total billed charges,52.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,87,58,,,percent of total billed charges,58% of total billed charges,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,127.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,30.56,135,
THERABAND YELLOW,5007124,CDM,270,RC,,,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,135,90,,,percent of total billed charges,90% of total billed charges,52.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,87,58,,,percent of total billed charges,58% of total billed charges,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,127.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,30.56,135,
THERABAND RED,5007125,CDM,270,RC,,,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,135,90,,,percent of total billed charges,90% of total billed charges,52.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,87,58,,,percent of total billed charges,58% of total billed charges,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,127.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,30.56,135,
THERABAND GREEN,5007126,CDM,270,RC,,,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,135,90,,,percent of total billed charges,90% of total billed charges,52.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,87,58,,,percent of total billed charges,58% of total billed charges,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,127.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,30.56,135,
THERABAND BLUE,5007127,CDM,270,RC,,,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,135,90,,,percent of total billed charges,90% of total billed charges,52.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,87,58,,,percent of total billed charges,58% of total billed charges,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,127.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,30.56,135,
THERABAND BLACK,5007128,CDM,270,RC,,,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,135,90,,,percent of total billed charges,90% of total billed charges,52.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,87,58,,,percent of total billed charges,58% of total billed charges,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,127.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,30.56,135,
THERABAND SILVER,5007129,CDM,270,RC,,,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,135,90,,,percent of total billed charges,90% of total billed charges,52.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,87,58,,,percent of total billed charges,58% of total billed charges,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,127.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,30.56,135,
AMBU BAG INFANT,7900001,CDM,270,RC,,,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,135,90,,,percent of total billed charges,90% of total billed charges,52.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,87,58,,,percent of total billed charges,58% of total billed charges,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,127.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,30.56,135,
UNNA FLEX,7905117,CDM,272,RC,,,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,135,90,,,percent of total billed charges,90% of total billed charges,52.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,87,58,,,percent of total billed charges,58% of total billed charges,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,127.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,30.56,135,
SUTURE 6-0 PROLENE 8697H,7905163,CDM,272,RC,,,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,135,90,,,percent of total billed charges,90% of total billed charges,52.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,87,58,,,percent of total billed charges,58% of total billed charges,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,127.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,30.56,135,
RIB BELT MALE ALL,7905307,CDM,274,RC,L0220,HCPCS,Both,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,135,90,,,percent of total billed charges,90% of total billed charges,52.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,87,58,,,percent of total billed charges,58% of total billed charges,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,127.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,30.56,135,
SURGICEL 2 X 14,7905533,CDM,272,RC,,,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,135,90,,,percent of total billed charges,90% of total billed charges,52.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,87,58,,,percent of total billed charges,58% of total billed charges,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,127.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,30.56,135,
MEDICOPASTE BANDAGE 4,7905721,CDM,270,RC,,,Outpatient,,,150,120,,127.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,84.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,135,90,,,percent of total billed charges,90% of total billed charges,52.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,103.05,68.7,,,percent of total billed charges,68.7% of total billed charges,120,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,87,58,,,percent of total billed charges,58% of total billed charges,30.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,127.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,30.56,135,
ADMIN 2ND PFIZER PEDIATRIC COVID19 VAC,2611117,CDM,771,RC,0072A,HCPCS,Outpatient,,,155,124,,131.75,85,,,percent of total billed charges,85% of total billed charges,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,31.57,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,87.58,56.5,,,percent of total billed charges,56.5 percent of total billed charges,87.58,56.5,,,percent of total billed charges,56.5 percent of total billed charges,87.58,56.5,,,percent of total billed charges,56.5 percent of total billed charges,87.58,56.5,,,percent of total billed charges,56.5 percent of total billed charges,35.88,102,,,fee schedule,Pays 102% Medicare OPPS,139.5,90,,,percent of total billed charges,90% of total billed charges,54.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,106.49,68.7,,,percent of total billed charges,68.7% of total billed charges,124,80,,,percent of total billed charges,80 percent of total billed charges,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,31.66,90,,,fee schedule,Pays 90% Medicare OPPS,89.9,58,,,percent of total billed charges,58% of total billed charges,31.57,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,31.57,139.5,
DRESSING SURGICAL AQUACEL AG 3.5 X 12,1570804,CDM,272,RC,,,Outpatient,,,160,128,,136,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,32.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,144,90,,,percent of total billed charges,90% of total billed charges,56,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,109.92,68.7,,,percent of total billed charges,68.7% of total billed charges,128,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,92.8,58,,,percent of total billed charges,58% of total billed charges,32.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,136,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,32.59,144,
PULSAVAC PLUS SHOWER KIT,1570851,CDM,272,RC,,,Outpatient,,,160,128,,136,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,32.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,144,90,,,percent of total billed charges,90% of total billed charges,56,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,109.92,68.7,,,percent of total billed charges,68.7% of total billed charges,128,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,92.8,58,,,percent of total billed charges,58% of total billed charges,32.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,136,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,32.59,144,
"Diphtheria, tetanus acellular, and pertussis vaccine for adults",2600184,CDM,259,RC,90715,HCPCS,Outpatient,,,160,128,,136,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,46.08,120.37,,,fee schedule,120.37% of custom fee schedule,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,144,90,,,percent of total billed charges,90% of total billed charges,47.92,125.18,,,fee schedule,125.18% of custom fee schedule,109.92,68.7,,,percent of total billed charges,68.7% of total billed charges,128,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,92.8,58,,,percent of total billed charges,58% of total billed charges,46.08,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,46.08,144,
LEVEMIR FLEXTOUCH 100UNITS/1ML,2605080,CDM,637,RC,J1815,HCPCS,Outpatient,,,160,128,,136,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,0.59,120.37,,,fee schedule,120.37% of custom fee schedule,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,144,90,,,percent of total billed charges,90% of total billed charges,0.61,125.18,,,fee schedule,125.18% of custom fee schedule,109.92,68.7,,,percent of total billed charges,68.7% of total billed charges,128,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,92.8,58,,,percent of total billed charges,58% of total billed charges,0.59,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,136,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.59,144,
ADMIN 2ND PFIZER DOSE COVID19 VACCINE,2611114,CDM,771,RC,0002A,HCPCS,Outpatient,,,160,128,,136,85,,,percent of total billed charges,85% of total billed charges,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,32.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,35.88,102,,,fee schedule,Pays 102% Medicare OPPS,144,90,,,percent of total billed charges,90% of total billed charges,56,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,109.92,68.7,,,percent of total billed charges,68.7% of total billed charges,128,80,,,percent of total billed charges,80 percent of total billed charges,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,31.66,90,,,fee schedule,Pays 90% Medicare OPPS,92.8,58,,,percent of total billed charges,58% of total billed charges,32.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,31.66,144,
3RD EHRLICHIA ANTIBODIES,3000096,CDM,300,RC,86666,HCPCS,Outpatient,,,160,128,,136,85,,,percent of total billed charges,85% of total billed charges,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,13.23,130,,,fee schedule,Pays 130% Medicare OPPS,15.41,120.37,,,fee schedule,120.37% of custom fee schedule,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,10.38,102,,,fee schedule,Pays 102% Medicare OPPS,144,90,,,percent of total billed charges,90% of total billed charges,16.02,125.18,,,fee schedule,125.18% of custom fee schedule,109.92,68.7,,,percent of total billed charges,68.7% of total billed charges,128,80,,,percent of total billed charges,80 percent of total billed charges,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,9.16,90,,,fee schedule,Pays 90% Medicare OPPS,92.8,58,,,percent of total billed charges,58% of total billed charges,15.41,120.37,,,fee schedule,120.37% of custom fee schedule,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,13.23,130,,,fee schedule,Pays 130% Medicare OPPS,136,85,,,percent of total billed charges,85% of total billed charges,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,9.16,144,
Testing for presence of drug,3000815,CDM,301,RC,80307,HCPCS,Outpatient,,,160,128,,136,85,,,percent of total billed charges,85% of total billed charges,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,80.78,130,,,fee schedule,Pays 130% Medicare OPPS,73.62,120.37,,,fee schedule,120.37% of custom fee schedule,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,63.38,102,,,fee schedule,Pays 102% Medicare OPPS,144,90,,,percent of total billed charges,90% of total billed charges,76.56,125.18,,,fee schedule,125.18% of custom fee schedule,109.92,68.7,,,percent of total billed charges,68.7% of total billed charges,128,80,,,percent of total billed charges,80 percent of total billed charges,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,55.92,90,,,fee schedule,Pays 90% Medicare OPPS,92.8,58,,,percent of total billed charges,58% of total billed charges,73.62,120.37,,,fee schedule,120.37% of custom fee schedule,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,80.78,130,,,fee schedule,Pays 130% Medicare OPPS,136,85,,,percent of total billed charges,85% of total billed charges,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,55.92,144,
RC AB ID/EACH PANEL & MEDIA,3008687,CDM,300,RC,86870,HCPCS,Outpatient,,,160,128,,136,85,,,percent of total billed charges,85% of total billed charges,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,370.6,130,,,fee schedule,Pays 130% Medicare OPPS,7.37,120.37,,,fee schedule,120.37% of custom fee schedule,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,266.86,102,,,fee schedule,Pays 102% Medicare OPPS,144,90,,,percent of total billed charges,90% of total billed charges,7.66,125.18,,,fee schedule,125.18% of custom fee schedule,109.92,68.7,,,percent of total billed charges,68.7% of total billed charges,128,80,,,percent of total billed charges,80 percent of total billed charges,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,235.46,90,,,fee schedule,Pays 90% Medicare OPPS,92.8,58,,,percent of total billed charges,58% of total billed charges,7.37,120.37,,,fee schedule,120.37% of custom fee schedule,285.08,100,,,fee schedule,Pays 100% Medicare OPPS,370.6,130,,,fee schedule,Pays 130% Medicare OPPS,136,85,,,percent of total billed charges,85% of total billed charges,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,7.37,370.6,
"RC PRETREATMENT OF RBC,INCUBATION",3086970,CDM,300,RC,86970,HCPCS,Outpatient,,,160,128,,136,85,,,percent of total billed charges,85% of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,38.83,130,,,fee schedule,Pays 130% Medicare OPPS,32.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.01,102,,,fee schedule,Pays 102% Medicare OPPS,144,90,,,percent of total billed charges,90% of total billed charges,56,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,109.92,68.7,,,percent of total billed charges,68.7% of total billed charges,128,80,,,percent of total billed charges,80 percent of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,27.36,90,,,fee schedule,Pays 90% Medicare OPPS,92.8,58,,,percent of total billed charges,58% of total billed charges,32.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,29.87,100,,,fee schedule,Pays 100% Medicare OPPS,38.83,130,,,fee schedule,Pays 130% Medicare OPPS,136,85,,,percent of total billed charges,85% of total billed charges,30.4,100,,,fee schedule,Pays 100% Medicare OPPS,27.36,144,
SURGIFOAM 8CM X 12.5CM X 1CM 1974,7905100,CDM,272,RC,,,Outpatient,,,160,128,,136,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,32.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,90.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,144,90,,,percent of total billed charges,90% of total billed charges,56,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,109.92,68.7,,,percent of total billed charges,68.7% of total billed charges,128,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,92.8,58,,,percent of total billed charges,58% of total billed charges,32.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,136,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,32.59,144,
STRESS TEST,405084,CDM,720,RC,59020,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,153.03,100,,,fee schedule,Pays 100% Medicare OPPS,153.03,100,,,fee schedule,Pays 100% Medicare OPPS,153.03,100,,,fee schedule,Pays 100% Medicare OPPS,203.67,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,156.09,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,153.03,100,,,fee schedule,Pays 100% Medicare OPPS,137.72,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,156.68,100,,,fee schedule,Pays 100% Medicare OPPS,203.67,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,153.03,100,,,fee schedule,Pays 100% Medicare OPPS,33.61,203.67,
SUTURE 3-0 CHROMIC 1638H,1570542,CDM,272,RC,,,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
EPIDURAL TRAY CE18HK,1805002,CDM,270,RC,,,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
ZOSYN 4.5GM VIAL,2600002,CDM,636,RC,,,Both,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
ZITHROMAX (AZITHROMYCIN) 1GM PACKET,2600024,CDM,637,RC,Q0144,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
CORTISPORIN TC OTIC SUSP 5ML,2600306,CDM,637,RC,,,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
ZOSYN INJ 3.375GM,2601056,CDM,636,RC,J2543,HCPCS,Both,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1.78,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,1.85,125.18,,,fee schedule,125.18% of custom fee schedule,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,1.78,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1.78,148.5,
AMINOPHYLLINE 500MG/20ML VIAL,2601254,CDM,636,RC,J0280,HCPCS,Both,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.21,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,8.54,125.18,,,fee schedule,125.18% of custom fee schedule,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,8.21,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.21,148.5,
ATROPINE OPTH SOLN 1% 5ML,2601265,CDM,250,RC,,,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
BREVIBLOC (ESMOLOL HCL) INJ 100MG,2601420,CDM,636,RC,,,Both,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
KENALOG-40 (TRIAMCINOLONE ACET) INJ 40MG,2602217,CDM,636,RC,J3301,HCPCS,Both,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1.31,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,1.36,125.18,,,fee schedule,125.18% of custom fee schedule,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,1.31,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1.31,148.5,
CEFZIL (CEFPROZIL) 125MG/5ML SUSP 50ML,2602323,CDM,637,RC,,,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
LEVAQUIN 250MG IV PREMIX,2602343,CDM,636,RC,J1956,HCPCS,Both,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
LANOXIN (DIGOXIN) ELX 0.25MG,2602685,CDM,637,RC,,,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
AA 4.5% DEX 10% : 1000ML,2611005,CDM,250,RC,,,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
ANTI La,3000014,CDM,302,RC,86235,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.28,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,28.23,125.18,,,fee schedule,125.18% of custom fee schedule,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,148.5,
ANTI RO,3000016,CDM,302,RC,86235,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.28,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,28.23,125.18,,,fee schedule,125.18% of custom fee schedule,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,148.5,
CENTROMERE ANTIB,3000044,CDM,302,RC,86235,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.28,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,28.23,125.18,,,fee schedule,125.18% of custom fee schedule,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,148.5,
MAGNESIUM URINE W/CREATININE,3000190,CDM,301,RC,83735,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,6.7,100,,,fee schedule,Pays 100% Medicare OPPS,6.7,100,,,fee schedule,Pays 100% Medicare OPPS,6.7,100,,,fee schedule,Pays 100% Medicare OPPS,8.71,130,,,fee schedule,Pays 130% Medicare OPPS,10.14,120.37,,,fee schedule,120.37% of custom fee schedule,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.83,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,10.54,125.18,,,fee schedule,125.18% of custom fee schedule,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,6.7,100,,,fee schedule,Pays 100% Medicare OPPS,6.03,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,10.14,120.37,,,fee schedule,120.37% of custom fee schedule,6.7,100,,,fee schedule,Pays 100% Medicare OPPS,8.71,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,6.7,100,,,fee schedule,Pays 100% Medicare OPPS,6.03,148.5,
PENICILLIN V IGE,3000228,CDM,302,RC,86003,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,148.5,
PENICILLIN G IGE,3000347,CDM,302,RC,86003,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,148.5,
...BLOOD ALCOHOL MULLINS,3000571,CDM,302,RC,82055,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
"ARSENIC, BLOOD",3000637,CDM,301,RC,82175,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,18.97,100,,,fee schedule,Pays 100% Medicare OPPS,18.97,100,,,fee schedule,Pays 100% Medicare OPPS,18.97,100,,,fee schedule,Pays 100% Medicare OPPS,24.66,130,,,fee schedule,Pays 130% Medicare OPPS,28.72,120.37,,,fee schedule,120.37% of custom fee schedule,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.34,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,29.87,125.18,,,fee schedule,125.18% of custom fee schedule,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,18.97,100,,,fee schedule,Pays 100% Medicare OPPS,17.07,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,28.72,120.37,,,fee schedule,120.37% of custom fee schedule,18.97,100,,,fee schedule,Pays 100% Medicare OPPS,24.66,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,18.97,100,,,fee schedule,Pays 100% Medicare OPPS,17.07,148.5,
.TESTOSTERONE ASSAY,3000643,CDM,301,RC,84402,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,25.47,100,,,fee schedule,Pays 100% Medicare OPPS,25.47,100,,,fee schedule,Pays 100% Medicare OPPS,25.47,100,,,fee schedule,Pays 100% Medicare OPPS,33.11,130,,,fee schedule,Pays 130% Medicare OPPS,38.53,120.37,,,fee schedule,120.37% of custom fee schedule,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.97,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,40.07,125.18,,,fee schedule,125.18% of custom fee schedule,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,25.47,100,,,fee schedule,Pays 100% Medicare OPPS,22.92,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,38.53,120.37,,,fee schedule,120.37% of custom fee schedule,25.47,100,,,fee schedule,Pays 100% Medicare OPPS,33.11,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,25.47,100,,,fee schedule,Pays 100% Medicare OPPS,22.92,148.5,
.SEX HORMOME GLOBUL,3000644,CDM,301,RC,84270,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,21.73,100,,,fee schedule,Pays 100% Medicare OPPS,21.73,100,,,fee schedule,Pays 100% Medicare OPPS,21.73,100,,,fee schedule,Pays 100% Medicare OPPS,28.24,130,,,fee schedule,Pays 130% Medicare OPPS,32.89,120.37,,,fee schedule,120.37% of custom fee schedule,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.16,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,34.2,125.18,,,fee schedule,125.18% of custom fee schedule,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,21.73,100,,,fee schedule,Pays 100% Medicare OPPS,19.55,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,32.89,120.37,,,fee schedule,120.37% of custom fee schedule,21.73,100,,,fee schedule,Pays 100% Medicare OPPS,28.24,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,21.73,100,,,fee schedule,Pays 100% Medicare OPPS,19.55,148.5,
AMOXICILLIN IGE,3000668,CDM,302,RC,86003,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,148.5,
AMPICILLIN IGE,3000669,CDM,302,RC,86003,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.32,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,8.22,125.18,,,fee schedule,125.18% of custom fee schedule,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,7.91,120.37,,,fee schedule,120.37% of custom fee schedule,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,6.78,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,5.22,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,148.5,
SMITH ANTIBODY,3000749,CDM,302,RC,86235,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.28,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,28.23,125.18,,,fee schedule,125.18% of custom fee schedule,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,148.5,
FINGERSTICK BLOOD SUGAR,3082956,CDM,301,RC,82948,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,6.55,130,,,fee schedule,Pays 130% Medicare OPPS,4.8,120.37,,,fee schedule,120.37% of custom fee schedule,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.14,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,4.99,125.18,,,fee schedule,125.18% of custom fee schedule,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,4.53,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,4.8,120.37,,,fee schedule,120.37% of custom fee schedule,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,6.55,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,4.53,148.5,
NS2 GLUCOSE STRIP/BEDSIDE,3082957,CDM,301,RC,82948,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,6.55,130,,,fee schedule,Pays 130% Medicare OPPS,4.8,120.37,,,fee schedule,120.37% of custom fee schedule,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.14,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,4.99,125.18,,,fee schedule,125.18% of custom fee schedule,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,4.53,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,4.8,120.37,,,fee schedule,120.37% of custom fee schedule,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,6.55,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,4.53,148.5,
ER GLUCOSE STRIP/BEDSIDE,3082958,CDM,301,RC,82948,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,6.55,130,,,fee schedule,Pays 130% Medicare OPPS,4.8,120.37,,,fee schedule,120.37% of custom fee schedule,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.14,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,4.99,125.18,,,fee schedule,125.18% of custom fee schedule,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,4.53,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,4.8,120.37,,,fee schedule,120.37% of custom fee schedule,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,6.55,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,4.53,148.5,
MON GLUCOSE STRIP/BEDSIDE,3082959,CDM,301,RC,82948,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,6.55,130,,,fee schedule,Pays 130% Medicare OPPS,4.8,120.37,,,fee schedule,120.37% of custom fee schedule,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.14,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,4.99,125.18,,,fee schedule,125.18% of custom fee schedule,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,4.53,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,4.8,120.37,,,fee schedule,120.37% of custom fee schedule,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,6.55,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,4.53,148.5,
L/D GLUCOSE STRIP/BEDSIDE,3082960,CDM,301,RC,82948,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,6.55,130,,,fee schedule,Pays 130% Medicare OPPS,4.8,120.37,,,fee schedule,120.37% of custom fee schedule,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.14,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,4.99,125.18,,,fee schedule,125.18% of custom fee schedule,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,4.53,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,4.8,120.37,,,fee schedule,120.37% of custom fee schedule,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,6.55,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,4.53,148.5,
REC GLUCOSE STRIP/BEDSIDE,3082961,CDM,301,RC,82948,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,6.55,130,,,fee schedule,Pays 130% Medicare OPPS,4.8,120.37,,,fee schedule,120.37% of custom fee schedule,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.14,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,4.99,125.18,,,fee schedule,125.18% of custom fee schedule,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,4.53,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,4.8,120.37,,,fee schedule,120.37% of custom fee schedule,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,6.55,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,5.04,100,,,fee schedule,Pays 100% Medicare OPPS,4.53,148.5,
3RD 5' NUCLEOTIDASE,3083915,CDM,302,RC,83915,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,11.15,100,,,fee schedule,Pays 100% Medicare OPPS,11.15,100,,,fee schedule,Pays 100% Medicare OPPS,11.15,100,,,fee schedule,Pays 100% Medicare OPPS,14.49,130,,,fee schedule,Pays 130% Medicare OPPS,16.88,120.37,,,fee schedule,120.37% of custom fee schedule,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.37,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,17.55,125.18,,,fee schedule,125.18% of custom fee schedule,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,11.15,100,,,fee schedule,Pays 100% Medicare OPPS,10.03,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,16.88,120.37,,,fee schedule,120.37% of custom fee schedule,11.15,100,,,fee schedule,Pays 100% Medicare OPPS,14.49,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,11.15,100,,,fee schedule,Pays 100% Medicare OPPS,10.03,148.5,
SEDIMENTATION RATE,3085651,CDM,305,RC,85651,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,5.55,130,,,fee schedule,Pays 130% Medicare OPPS,5.37,120.37,,,fee schedule,120.37% of custom fee schedule,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.35,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,5.58,125.18,,,fee schedule,125.18% of custom fee schedule,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,3.84,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,5.37,120.37,,,fee schedule,120.37% of custom fee schedule,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,5.55,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,4.26,100,,,fee schedule,Pays 100% Medicare OPPS,3.84,148.5,
Blood test to determine cause of inappropriate blood clot formation,3086147,CDM,302,RC,86147,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,25.45,100,,,fee schedule,Pays 100% Medicare OPPS,25.45,100,,,fee schedule,Pays 100% Medicare OPPS,25.45,100,,,fee schedule,Pays 100% Medicare OPPS,33.08,130,,,fee schedule,Pays 130% Medicare OPPS,38.51,120.37,,,fee schedule,120.37% of custom fee schedule,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.95,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,40.05,125.18,,,fee schedule,125.18% of custom fee schedule,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,25.45,100,,,fee schedule,Pays 100% Medicare OPPS,22.9,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,38.51,120.37,,,fee schedule,120.37% of custom fee schedule,25.45,100,,,fee schedule,Pays 100% Medicare OPPS,33.08,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,25.45,100,,,fee schedule,Pays 100% Medicare OPPS,22.9,148.5,
RC ANTIBODY/EACH PANEL & MEDIA,3086870,CDM,300,RC,86870,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,370.6,130,,,fee schedule,Pays 130% Medicare OPPS,7.37,120.37,,,fee schedule,120.37% of custom fee schedule,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,266.86,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,7.66,125.18,,,fee schedule,125.18% of custom fee schedule,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,235.46,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,7.37,120.37,,,fee schedule,120.37% of custom fee schedule,285.08,100,,,fee schedule,Pays 100% Medicare OPPS,370.6,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,7.37,370.6,
XR CYSTO CONRAY,4000037,CDM,255,RC,,,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,33.61,148.5,
NM TC99M UNIT DOSE/THYROID,4500002,CDM,255,RC,,,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,33.61,148.5,
NM TC99M DTPA,4500006,CDM,343,RC,A9539,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
NM TC99M MAA 10 MCI,4500007,CDM,343,RC,A9540,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
NM TC99M MICROLITE,4500008,CDM,255,RC,,,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,33.61,148.5,
NM TC04 TECHNETATE,4500014,CDM,341,RC,A9500,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
NM PYP KIT,4500024,CDM,270,RC,,,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
NM TC99M SULFUR COLLOID,4500036,CDM,343,RC,A9541,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
NM TC99M HDP,4500038,CDM,255,RC,,,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,33.61,148.5,
Form of decompression therapy of the spine,5007012,CDM,420,RC,97012,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,13.82,100,,,fee schedule,Pays 100% Medicare OPPS,13.82,100,,,fee schedule,Pays 100% Medicare OPPS,13.82,100,,,fee schedule,Pays 100% Medicare OPPS,18.06,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.1,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,13.82,100,,,fee schedule,Pays 100% Medicare OPPS,12.44,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,13.89,100,,,fee schedule,Pays 100% Medicare OPPS,18.06,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,13.82,100,,,fee schedule,Pays 100% Medicare OPPS,12.44,148.5,
One time use unattended,5007014,CDM,420,RC,97014,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,5007033,CDM,420,RC,97033,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,18.72,100,,,fee schedule,Pays 100% Medicare OPPS,18.72,100,,,fee schedule,Pays 100% Medicare OPPS,18.72,100,,,fee schedule,Pays 100% Medicare OPPS,24.31,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.09,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,18.72,100,,,fee schedule,Pays 100% Medicare OPPS,16.85,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,18.7,100,,,fee schedule,Pays 100% Medicare OPPS,24.31,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,18.72,100,,,fee schedule,Pays 100% Medicare OPPS,16.85,148.5,
SPLINT ANTI-SPASTICITY BALL MED LEFT,5007120,CDM,270,RC,,,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
SPLINT ANTI-SPASTICITY BALL MED RIGHT,5007121,CDM,270,RC,,,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
PAPER BLUE COVER 8-1/2 X 11,5007530,CDM,270,RC,,,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
BRACE KNEE PALUMBO 62146 MED,5007532,CDM,270,RC,,,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
BRACE KNEE PALUMBO 62146 MED/LG,5007533,CDM,270,RC,,,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
BRACE KNEE PALUMBO 62146 LG,5007540,CDM,270,RC,,,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
BRACE KNEE PALUMBO 62146 XLG,5007541,CDM,270,RC,,,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
PT UNATTEN ELECT STIMULA(PER SESSION),5010283,CDM,420,RC,G0283,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,11.7,100,,,fee schedule,Pays 100% Medicare OPPS,11.7,100,,,fee schedule,Pays 100% Medicare OPPS,11.7,100,,,fee schedule,Pays 100% Medicare OPPS,14.96,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.93,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,11.7,100,,,fee schedule,Pays 100% Medicare OPPS,10.53,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.51,100,,,fee schedule,Pays 100% Medicare OPPS,14.96,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,11.7,100,,,fee schedule,Pays 100% Medicare OPPS,10.53,148.5,
PT TENS FITTING APPLIC (PER SESSION),5064550,CDM,420,RC,64550,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
PT ROM EXTREMITY NOT HAND,5095851,CDM,420,RC,95851,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,19.21,100,,,fee schedule,Pays 100% Medicare OPPS,19.21,100,,,fee schedule,Pays 100% Medicare OPPS,19.21,100,,,fee schedule,Pays 100% Medicare OPPS,9.82,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.59,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,19.21,100,,,fee schedule,Pays 100% Medicare OPPS,17.29,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,7.55,100,,,fee schedule,Pays 100% Medicare OPPS,9.82,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,19.21,100,,,fee schedule,Pays 100% Medicare OPPS,7.55,148.5,
Form of decompression therapy of the spine,5097012,CDM,420,RC,97012,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,13.82,100,,,fee schedule,Pays 100% Medicare OPPS,13.82,100,,,fee schedule,Pays 100% Medicare OPPS,13.82,100,,,fee schedule,Pays 100% Medicare OPPS,18.06,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.1,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,13.82,100,,,fee schedule,Pays 100% Medicare OPPS,12.44,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,13.89,100,,,fee schedule,Pays 100% Medicare OPPS,18.06,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,13.82,100,,,fee schedule,Pays 100% Medicare OPPS,12.44,148.5,
One time use unattended,5097014,CDM,420,RC,97014,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
"Machines designed to pump cold water into an inflatable wrap or brace, compressing the enveloped area of the body",5097016,CDM,420,RC,97016,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,11.4,100,,,fee schedule,Pays 100% Medicare OPPS,11.4,100,,,fee schedule,Pays 100% Medicare OPPS,11.4,100,,,fee schedule,Pays 100% Medicare OPPS,14.59,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.63,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,11.4,100,,,fee schedule,Pays 100% Medicare OPPS,10.26,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.22,100,,,fee schedule,Pays 100% Medicare OPPS,14.59,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,11.4,100,,,fee schedule,Pays 100% Medicare OPPS,10.26,148.5,
PT WHIRLPOOL (PER SESSION),5097022,CDM,420,RC,97022,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,16.22,100,,,fee schedule,Pays 100% Medicare OPPS,16.22,100,,,fee schedule,Pays 100% Medicare OPPS,16.22,100,,,fee schedule,Pays 100% Medicare OPPS,20.74,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.54,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,16.22,100,,,fee schedule,Pays 100% Medicare OPPS,14.6,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,15.95,100,,,fee schedule,Pays 100% Medicare OPPS,20.74,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,16.22,100,,,fee schedule,Pays 100% Medicare OPPS,14.6,148.5,
Repeated application to one or more parts of the body,5097032,CDM,420,RC,97032,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,14.12,100,,,fee schedule,Pays 100% Medicare OPPS,14.12,100,,,fee schedule,Pays 100% Medicare OPPS,14.12,100,,,fee schedule,Pays 100% Medicare OPPS,18.06,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.4,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,14.12,100,,,fee schedule,Pays 100% Medicare OPPS,12.71,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,13.89,100,,,fee schedule,Pays 100% Medicare OPPS,18.06,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,14.12,100,,,fee schedule,Pays 100% Medicare OPPS,12.71,148.5,
Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,5097033,CDM,420,RC,97033,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,18.72,100,,,fee schedule,Pays 100% Medicare OPPS,18.72,100,,,fee schedule,Pays 100% Medicare OPPS,18.72,100,,,fee schedule,Pays 100% Medicare OPPS,24.31,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.09,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,18.72,100,,,fee schedule,Pays 100% Medicare OPPS,16.85,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,18.7,100,,,fee schedule,Pays 100% Medicare OPPS,24.31,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,18.72,100,,,fee schedule,Pays 100% Medicare OPPS,16.85,148.5,
PT CONTRAST BATH (PER 15 MINS),5097034,CDM,420,RC,97034,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,13.96,100,,,fee schedule,Pays 100% Medicare OPPS,13.96,100,,,fee schedule,Pays 100% Medicare OPPS,13.96,100,,,fee schedule,Pays 100% Medicare OPPS,17.84,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.24,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,13.96,100,,,fee schedule,Pays 100% Medicare OPPS,12.56,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,13.72,100,,,fee schedule,Pays 100% Medicare OPPS,17.84,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,13.96,100,,,fee schedule,Pays 100% Medicare OPPS,12.56,148.5,
PT MECHAN MODALITY (PER 15 MINS),5097039,CDM,420,RC,97039,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
PT GROUP THER PROC (PER SESSION),5097150,CDM,420,RC,97150,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,17.03,100,,,fee schedule,Pays 100% Medicare OPPS,17.03,100,,,fee schedule,Pays 100% Medicare OPPS,17.03,100,,,fee schedule,Pays 100% Medicare OPPS,22.14,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.37,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,17.03,100,,,fee schedule,Pays 100% Medicare OPPS,15.33,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,17.03,100,,,fee schedule,Pays 100% Medicare OPPS,22.14,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,17.03,100,,,fee schedule,Pays 100% Medicare OPPS,15.33,148.5,
PT PHY PERFM TEST (PER 15 MINS),5097750,CDM,420,RC,97750,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,31.99,100,,,fee schedule,Pays 100% Medicare OPPS,31.99,100,,,fee schedule,Pays 100% Medicare OPPS,31.99,100,,,fee schedule,Pays 100% Medicare OPPS,41.61,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,32.63,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,31.99,100,,,fee schedule,Pays 100% Medicare OPPS,28.79,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,32.01,100,,,fee schedule,Pays 100% Medicare OPPS,41.61,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,31.99,100,,,fee schedule,Pays 100% Medicare OPPS,28.79,148.5,
PT PROST/ORTHOT CK (PER 15 MINS),5097762,CDM,420,RC,97762,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
OT APPLICATION ARM SPLINT(PER SESSION),5129125,CDM,430,RC,29125,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,33.61,148.5,
OT APPLICAT FINGER SPLT S (PER SESSION),5129130,CDM,430,RC,29130,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,33.61,148.5,
OT APPLICAT FINGER SPLT D (PER SESSION),5129131,CDM,430,RC,29131,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,65.72,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,51,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,45,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,50.55,100,,,fee schedule,Pays 100% Medicare OPPS,65.72,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,33.61,148.5,
OT STRAPPING OF THORAX (PER SESSION),5129200,CDM,430,RC,29200,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,166.66,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,129.44,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,114.22,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,128.19,100,,,fee schedule,Pays 100% Medicare OPPS,166.66,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,33.61,166.66,
OT STRAPPING OF LOW BACK (PER SESSION),5129220,CDM,430,RC,29799,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,166.66,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,129.44,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,114.22,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,128.19,100,,,fee schedule,Pays 100% Medicare OPPS,166.66,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,33.61,166.66,
OT STRAPPING OF SHOULDER (PER SESSION),5129240,CDM,430,RC,29240,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,33.61,148.5,
OT STRAPPING ELBOW OR WRI (PER SESSION),5129260,CDM,430,RC,29260,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,65.72,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,51,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,45,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,50.55,100,,,fee schedule,Pays 100% Medicare OPPS,65.72,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,33.61,148.5,
OT STRAPPING HAND OR FING (PER SESSION),5129280,CDM,430,RC,29280,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,65.72,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,51,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,45,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,50.55,100,,,fee schedule,Pays 100% Medicare OPPS,65.72,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,33.61,148.5,
OT APPLICAT S ARM SPLT DY(PER SESSION),5179126,CDM,430,RC,29126,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,33.61,148.5,
Repeated application to one or more parts of the body,5197032,CDM,430,RC,97032,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,14.12,100,,,fee schedule,Pays 100% Medicare OPPS,14.12,100,,,fee schedule,Pays 100% Medicare OPPS,14.12,100,,,fee schedule,Pays 100% Medicare OPPS,18.06,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.4,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,14.12,100,,,fee schedule,Pays 100% Medicare OPPS,12.71,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,13.89,100,,,fee schedule,Pays 100% Medicare OPPS,18.06,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,14.12,100,,,fee schedule,Pays 100% Medicare OPPS,12.71,148.5,
Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,5197033,CDM,430,RC,97033,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,18.72,100,,,fee schedule,Pays 100% Medicare OPPS,18.72,100,,,fee schedule,Pays 100% Medicare OPPS,18.72,100,,,fee schedule,Pays 100% Medicare OPPS,24.31,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.09,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,18.72,100,,,fee schedule,Pays 100% Medicare OPPS,16.85,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,18.7,100,,,fee schedule,Pays 100% Medicare OPPS,24.31,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,18.72,100,,,fee schedule,Pays 100% Medicare OPPS,16.85,148.5,
OT CONTRAST BATH (PER 15 MINS),5197034,CDM,430,RC,97034,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,13.96,100,,,fee schedule,Pays 100% Medicare OPPS,13.96,100,,,fee schedule,Pays 100% Medicare OPPS,13.96,100,,,fee schedule,Pays 100% Medicare OPPS,17.84,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.24,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,13.96,100,,,fee schedule,Pays 100% Medicare OPPS,12.56,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,13.72,100,,,fee schedule,Pays 100% Medicare OPPS,17.84,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,13.96,100,,,fee schedule,Pays 100% Medicare OPPS,12.56,148.5,
OT GROUP THERAPEUTIC PROC (PER SESSION),5197150,CDM,430,RC,97150,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,17.03,100,,,fee schedule,Pays 100% Medicare OPPS,17.03,100,,,fee schedule,Pays 100% Medicare OPPS,17.03,100,,,fee schedule,Pays 100% Medicare OPPS,22.14,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.37,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,17.03,100,,,fee schedule,Pays 100% Medicare OPPS,15.33,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,17.03,100,,,fee schedule,Pays 100% Medicare OPPS,22.14,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,17.03,100,,,fee schedule,Pays 100% Medicare OPPS,15.33,148.5,
OT COGNITIVE SKILLS DEVEL(PER 15 MINS),5197532,CDM,430,RC,97532,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
OT SENSORY INTEGRAT (PER 15 MINS),5197533,CDM,430,RC,97533,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,60.07,100,,,fee schedule,Pays 100% Medicare OPPS,60.07,100,,,fee schedule,Pays 100% Medicare OPPS,60.07,100,,,fee schedule,Pays 100% Medicare OPPS,76.31,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,61.27,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,60.07,100,,,fee schedule,Pays 100% Medicare OPPS,54.06,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,58.7,100,,,fee schedule,Pays 100% Medicare OPPS,76.31,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,60.07,100,,,fee schedule,Pays 100% Medicare OPPS,33.61,148.5,
Occupational therapy,5197535,CDM,430,RC,97535,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,31.39,100,,,fee schedule,Pays 100% Medicare OPPS,31.39,100,,,fee schedule,Pays 100% Medicare OPPS,31.39,100,,,fee schedule,Pays 100% Medicare OPPS,40.44,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,32.02,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,31.39,100,,,fee schedule,Pays 100% Medicare OPPS,28.25,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,31.11,100,,,fee schedule,Pays 100% Medicare OPPS,40.44,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,31.39,100,,,fee schedule,Pays 100% Medicare OPPS,28.25,148.5,
OT NERVE & MUSCLE TESTING (PER 15 MINS),5197750,CDM,430,RC,97750,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,31.99,100,,,fee schedule,Pays 100% Medicare OPPS,31.99,100,,,fee schedule,Pays 100% Medicare OPPS,31.99,100,,,fee schedule,Pays 100% Medicare OPPS,41.61,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,32.63,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,31.99,100,,,fee schedule,Pays 100% Medicare OPPS,28.79,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,32.01,100,,,fee schedule,Pays 100% Medicare OPPS,41.61,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,31.99,100,,,fee schedule,Pays 100% Medicare OPPS,28.79,148.5,
OT PROSTHETIC TRAIN/FAB (PER 15 MINS),5197761,CDM,430,RC,97761,HCPCS,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,39.5,100,,,fee schedule,Pays 100% Medicare OPPS,39.5,100,,,fee schedule,Pays 100% Medicare OPPS,39.5,100,,,fee schedule,Pays 100% Medicare OPPS,51.18,130,,,fee schedule,Pays 130% Medicare OPPS,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,40.29,102,,,fee schedule,Pays 102% Medicare OPPS,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,39.5,100,,,fee schedule,Pays 100% Medicare OPPS,35.55,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,39.37,100,,,fee schedule,Pays 100% Medicare OPPS,51.18,130,,,fee schedule,Pays 130% Medicare OPPS,140.25,85,,,percent of total billed charges,85% of total billed charges,39.5,100,,,fee schedule,Pays 100% Medicare OPPS,33.61,148.5,
CATH KIT CENTRAL VENOUS C-PMS-631J,7905497,CDM,270,RC,,,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
MONITORCENTRAL VENOUS,7905500,CDM,270,RC,,,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
TRACHEOSTOMY TUBE SZ 6 DFEN,7905576,CDM,272,RC,,,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
***DO NOT USE***,7905987,CDM,270,RC,,,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
SPLINT THUMBKEEPER/592X,7907172,CDM,270,RC,,,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
.................CROUP TENT CANOPY 2352,7919430,CDM,270,RC,,,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
STAPLE RELOADS,7950180,CDM,272,RC,,,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
NEEDLE BIOPSY TRU-CUT 18 GA. X 6,7950252,CDM,270,RC,,,Outpatient,,,165,132,,140.25,85,,,percent of total billed charges,85% of total billed charges,41.25,100,,,fee schedule,Pays 100% Medicare OPPS,41.25,100,,,fee schedule,Pays 100% Medicare OPPS,41.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,93.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,percent of total billed charges,90% of total billed charges,57.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,113.36,68.7,,,percent of total billed charges,68.7% of total billed charges,132,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,148.5,90,,,fee schedule,Pays 90% Medicare OPPS,95.7,58,,,percent of total billed charges,58% of total billed charges,33.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,33.61,148.5,
IV HYDRATION ADDITIONAL HRS,1090761,CDM,760,RC,96361,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.65,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,59.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,37.26,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,153,
IV HYDRATION ADDITIONAL HRS,1590761,CDM,760,RC,96361,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.65,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,59.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,37.26,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,153,
IV HYDRATION ADDTL HR,2090761,CDM,450,RC,96361,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.65,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,59.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,37.26,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,153,
IV SET VENO-78 MIS,2600005,CDM,270,RC,,,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,153,90,,,percent of total billed charges,90% of total billed charges,59.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,153,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,144.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,34.63,153,
IV SET MICRODRIP,2600023,CDM,270,RC,,,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,153,90,,,percent of total billed charges,90% of total billed charges,59.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,153,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,144.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,34.63,153,
ANCEF (CEFAZOLIN) INJ 1GM,2600036,CDM,636,RC,J0690,HCPCS,Both,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.87,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,153,90,,,percent of total billed charges,90% of total billed charges,0.9,125.18,,,fee schedule,125.18% of custom fee schedule,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,153,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,0.87,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,144.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.87,153,
STERILE WATER FOR INJECTION 1000ML,2600117,CDM,250,RC,,,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,153,90,,,percent of total billed charges,90% of total billed charges,59.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,153,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,144.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,34.63,153,
BETOPTIC (BETAXOLOL) 0.5% OPHTH SOL,2600302,CDM,637,RC,,,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,153,90,,,percent of total billed charges,90% of total billed charges,59.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,153,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,144.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,34.63,153,
BSS IRR (BAL SALT SOLUTION):500ML,2601288,CDM,637,RC,,,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,153,90,,,percent of total billed charges,90% of total billed charges,59.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,153,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,144.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,34.63,153,
DIFLUCAN (FLUCONAZOLE) 200MG IV PREMIX,2601295,CDM,250,RC,J1450,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.14,120.37,,,fee schedule,120.37% of custom fee schedule,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,153,90,,,percent of total billed charges,90% of total billed charges,3.27,125.18,,,fee schedule,125.18% of custom fee schedule,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,153,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,3.14,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,144.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.14,153,
ZEMURON (ROCURONIUM) INJ 50MG,2603007,CDM,250,RC,,,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,153,90,,,percent of total billed charges,90% of total billed charges,59.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,153,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,144.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,34.63,153,
IV PCA PUMP SET MED,2610519,CDM,637,RC,,,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,153,90,,,percent of total billed charges,90% of total billed charges,59.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,153,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,144.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,34.63,153,
"ENCEPH,CALIFORNIA IgM",3000097,CDM,302,RC,86651,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,17.14,130,,,fee schedule,Pays 130% Medicare OPPS,19.97,120.37,,,fee schedule,120.37% of custom fee schedule,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.45,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,20.77,125.18,,,fee schedule,125.18% of custom fee schedule,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,11.87,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,19.97,120.37,,,fee schedule,120.37% of custom fee schedule,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,17.14,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,11.87,153,
"ENCEPH,E.EQUINE IgM",3000098,CDM,302,RC,86652,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,17.14,130,,,fee schedule,Pays 130% Medicare OPPS,19.97,120.37,,,fee schedule,120.37% of custom fee schedule,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.45,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,20.77,125.18,,,fee schedule,125.18% of custom fee schedule,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,11.87,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,19.97,120.37,,,fee schedule,120.37% of custom fee schedule,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,17.14,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,11.87,153,
"ENCEPH,ST. LOUIS IgM",3000099,CDM,302,RC,86653,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,17.14,130,,,fee schedule,Pays 130% Medicare OPPS,19.97,120.37,,,fee schedule,120.37% of custom fee schedule,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.45,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,20.77,125.18,,,fee schedule,125.18% of custom fee schedule,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,11.87,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,19.97,120.37,,,fee schedule,120.37% of custom fee schedule,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,17.14,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,11.87,153,
WESTERN EQUINE IgM,3000100,CDM,302,RC,86654,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,17.14,130,,,fee schedule,Pays 130% Medicare OPPS,19.97,120.37,,,fee schedule,120.37% of custom fee schedule,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.45,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,20.77,125.18,,,fee schedule,125.18% of custom fee schedule,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,11.87,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,19.97,120.37,,,fee schedule,120.37% of custom fee schedule,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,17.14,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,11.87,153,
RICKETTSIA IgM,3000261,CDM,302,RC,86757,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,25.15,130,,,fee schedule,Pays 130% Medicare OPPS,29.31,120.37,,,fee schedule,120.37% of custom fee schedule,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.73,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,30.48,125.18,,,fee schedule,125.18% of custom fee schedule,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,17.41,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,29.31,120.37,,,fee schedule,120.37% of custom fee schedule,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,25.15,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,17.41,153,
.ROCKY MOUNT SPOT FEV IgG,3000267,CDM,302,RC,86757,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,25.15,130,,,fee schedule,Pays 130% Medicare OPPS,29.31,120.37,,,fee schedule,120.37% of custom fee schedule,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.73,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,30.48,125.18,,,fee schedule,125.18% of custom fee schedule,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,17.41,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,29.31,120.37,,,fee schedule,120.37% of custom fee schedule,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,25.15,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,17.41,153,
.ROCKY MOUNT SPOT FEV IgM,3000268,CDM,302,RC,86757,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,25.15,130,,,fee schedule,Pays 130% Medicare OPPS,29.31,120.37,,,fee schedule,120.37% of custom fee schedule,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.73,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,30.48,125.18,,,fee schedule,125.18% of custom fee schedule,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,17.41,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,29.31,120.37,,,fee schedule,120.37% of custom fee schedule,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,25.15,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,17.41,153,
RSV ANTIBODY IgM,3000271,CDM,302,RC,86756,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,15.89,100,,,fee schedule,Pays 100% Medicare OPPS,15.89,100,,,fee schedule,Pays 100% Medicare OPPS,15.89,100,,,fee schedule,Pays 100% Medicare OPPS,20.65,130,,,fee schedule,Pays 130% Medicare OPPS,19.51,120.37,,,fee schedule,120.37% of custom fee schedule,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.2,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,20.29,125.18,,,fee schedule,125.18% of custom fee schedule,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,15.89,100,,,fee schedule,Pays 100% Medicare OPPS,14.3,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,19.51,120.37,,,fee schedule,120.37% of custom fee schedule,15.89,100,,,fee schedule,Pays 100% Medicare OPPS,20.65,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,15.89,100,,,fee schedule,Pays 100% Medicare OPPS,14.3,153,
.........SMITH AB,3000284,CDM,302,RC,86235,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.28,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,28.23,125.18,,,fee schedule,125.18% of custom fee schedule,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,153,
"Blood test, clotting time",3000360,CDM,301,RC,85610,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,4.29,100,,,fee schedule,Pays 100% Medicare OPPS,4.29,100,,,fee schedule,Pays 100% Medicare OPPS,4.29,100,,,fee schedule,Pays 100% Medicare OPPS,5.57,130,,,fee schedule,Pays 130% Medicare OPPS,5.95,120.37,,,fee schedule,120.37% of custom fee schedule,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.37,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,6.18,125.18,,,fee schedule,125.18% of custom fee schedule,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,4.29,100,,,fee schedule,Pays 100% Medicare OPPS,3.86,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,5.95,120.37,,,fee schedule,120.37% of custom fee schedule,4.29,100,,,fee schedule,Pays 100% Medicare OPPS,5.57,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,4.29,100,,,fee schedule,Pays 100% Medicare OPPS,3.86,153,
"Blood test, clotting time",3000372,CDM,301,RC,85610,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,4.29,100,,,fee schedule,Pays 100% Medicare OPPS,4.29,100,,,fee schedule,Pays 100% Medicare OPPS,4.29,100,,,fee schedule,Pays 100% Medicare OPPS,5.57,130,,,fee schedule,Pays 130% Medicare OPPS,5.95,120.37,,,fee schedule,120.37% of custom fee schedule,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.37,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,6.18,125.18,,,fee schedule,125.18% of custom fee schedule,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,4.29,100,,,fee schedule,Pays 100% Medicare OPPS,3.86,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,5.95,120.37,,,fee schedule,120.37% of custom fee schedule,4.29,100,,,fee schedule,Pays 100% Medicare OPPS,5.57,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,4.29,100,,,fee schedule,Pays 100% Medicare OPPS,3.86,153,
................RNP ANTIBODY,3000638,CDM,302,RC,86235,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.28,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,28.23,125.18,,,fee schedule,125.18% of custom fee schedule,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,153,
".PROTEIN, WESTERN BLOT",3084181,CDM,300,RC,84181,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,17.03,100,,,fee schedule,Pays 100% Medicare OPPS,17.03,100,,,fee schedule,Pays 100% Medicare OPPS,17.03,100,,,fee schedule,Pays 100% Medicare OPPS,22.13,130,,,fee schedule,Pays 130% Medicare OPPS,25.78,120.37,,,fee schedule,120.37% of custom fee schedule,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.37,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,26.81,125.18,,,fee schedule,125.18% of custom fee schedule,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,17.03,100,,,fee schedule,Pays 100% Medicare OPPS,15.32,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,25.78,120.37,,,fee schedule,120.37% of custom fee schedule,17.03,100,,,fee schedule,Pays 100% Medicare OPPS,22.13,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,17.03,100,,,fee schedule,Pays 100% Medicare OPPS,15.32,153,
"ENCEPH,CALIFORNIA IgG",3086651,CDM,302,RC,86651,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,17.14,130,,,fee schedule,Pays 130% Medicare OPPS,19.97,120.37,,,fee schedule,120.37% of custom fee schedule,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.45,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,20.77,125.18,,,fee schedule,125.18% of custom fee schedule,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,11.87,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,19.97,120.37,,,fee schedule,120.37% of custom fee schedule,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,17.14,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,11.87,153,
"ENCEPH,E.EQUINE IgG",3086652,CDM,302,RC,86652,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,17.14,130,,,fee schedule,Pays 130% Medicare OPPS,19.97,120.37,,,fee schedule,120.37% of custom fee schedule,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.45,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,20.77,125.18,,,fee schedule,125.18% of custom fee schedule,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,11.87,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,19.97,120.37,,,fee schedule,120.37% of custom fee schedule,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,17.14,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,11.87,153,
"ENCEPH,ST. LOUIS IgG",3086653,CDM,302,RC,86653,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,17.14,130,,,fee schedule,Pays 130% Medicare OPPS,19.97,120.37,,,fee schedule,120.37% of custom fee schedule,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.45,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,20.77,125.18,,,fee schedule,125.18% of custom fee schedule,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,11.87,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,19.97,120.37,,,fee schedule,120.37% of custom fee schedule,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,17.14,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,11.87,153,
WESTERN EQUINE IgG,3086654,CDM,302,RC,86654,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,17.14,130,,,fee schedule,Pays 130% Medicare OPPS,19.97,120.37,,,fee schedule,120.37% of custom fee schedule,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.45,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,20.77,125.18,,,fee schedule,125.18% of custom fee schedule,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,11.87,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,19.97,120.37,,,fee schedule,120.37% of custom fee schedule,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,17.14,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,11.87,153,
RSV ANTIBODY IgG,3086756,CDM,302,RC,86756,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,15.89,100,,,fee schedule,Pays 100% Medicare OPPS,15.89,100,,,fee schedule,Pays 100% Medicare OPPS,15.89,100,,,fee schedule,Pays 100% Medicare OPPS,20.65,130,,,fee schedule,Pays 130% Medicare OPPS,19.51,120.37,,,fee schedule,120.37% of custom fee schedule,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.2,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,20.29,125.18,,,fee schedule,125.18% of custom fee schedule,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,15.89,100,,,fee schedule,Pays 100% Medicare OPPS,14.3,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,19.51,120.37,,,fee schedule,120.37% of custom fee schedule,15.89,100,,,fee schedule,Pays 100% Medicare OPPS,20.65,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,15.89,100,,,fee schedule,Pays 100% Medicare OPPS,14.3,153,
RICKETTSIA IgG,3086757,CDM,302,RC,86757,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,25.15,130,,,fee schedule,Pays 130% Medicare OPPS,29.31,120.37,,,fee schedule,120.37% of custom fee schedule,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.73,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,30.48,125.18,,,fee schedule,125.18% of custom fee schedule,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,17.41,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,29.31,120.37,,,fee schedule,120.37% of custom fee schedule,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,25.15,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,17.41,153,
88173 CP INTERPRETATION AND REPORT,3200004,CDM,311,RC,88173,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,57.33,130,,,fee schedule,Pays 130% Medicare OPPS,110.23,120.37,,,fee schedule,120.37% of custom fee schedule,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.53,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,114.64,125.18,,,fee schedule,125.18% of custom fee schedule,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,40.17,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,110.23,120.37,,,fee schedule,120.37% of custom fee schedule,44.1,100,,,fee schedule,Pays 100% Medicare OPPS,57.33,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,40.17,153,
88304 SURGICAL PATHOLOGY LEVEL III,3200007,CDM,310,RC,88304,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,57.33,130,,,fee schedule,Pays 130% Medicare OPPS,36.33,120.37,,,fee schedule,120.37% of custom fee schedule,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.53,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,37.78,125.18,,,fee schedule,125.18% of custom fee schedule,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,40.17,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,36.33,120.37,,,fee schedule,120.37% of custom fee schedule,44.1,100,,,fee schedule,Pays 100% Medicare OPPS,57.33,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,36.33,153,
Test of tissues for diagnosis of abnormalities,3200008,CDM,310,RC,88305,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,57.33,130,,,fee schedule,Pays 130% Medicare OPPS,79.3,120.37,,,fee schedule,120.37% of custom fee schedule,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.53,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,82.47,125.18,,,fee schedule,125.18% of custom fee schedule,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,40.17,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,79.3,120.37,,,fee schedule,120.37% of custom fee schedule,44.1,100,,,fee schedule,Pays 100% Medicare OPPS,57.33,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,40.17,153,
Pathology test,3200014,CDM,310,RC,88342,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,179.8,130,,,fee schedule,Pays 130% Medicare OPPS,86.16,120.37,,,fee schedule,120.37% of custom fee schedule,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,136.65,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,89.6,125.18,,,fee schedule,125.18% of custom fee schedule,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,120.57,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,86.16,120.37,,,fee schedule,120.37% of custom fee schedule,138.31,100,,,fee schedule,Pays 100% Medicare OPPS,179.8,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,86.16,179.8,
IV HYDRATION ADDITIONAL HRS,4090761,CDM,760,RC,96361,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.65,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,59.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,37.26,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,153,
NM TC99M MAG 3 PER M,4500012,CDM,255,RC,A9540,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,153,90,,,percent of total billed charges,90% of total billed charges,59.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,153,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,34.63,153,
PT SENSORY INTEGRAT(PER 15 MINS),5097533,CDM,420,RC,97533,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,60.07,100,,,fee schedule,Pays 100% Medicare OPPS,60.07,100,,,fee schedule,Pays 100% Medicare OPPS,60.07,100,,,fee schedule,Pays 100% Medicare OPPS,76.31,130,,,fee schedule,Pays 130% Medicare OPPS,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,61.27,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,59.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,60.07,100,,,fee schedule,Pays 100% Medicare OPPS,54.06,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,58.7,100,,,fee schedule,Pays 100% Medicare OPPS,76.31,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,60.07,100,,,fee schedule,Pays 100% Medicare OPPS,34.63,153,
OT COMMUNITY WORK REENTRY (PER 15 MINS),5197537,CDM,430,RC,97537,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,30.6,100,,,fee schedule,Pays 100% Medicare OPPS,30.6,100,,,fee schedule,Pays 100% Medicare OPPS,30.6,100,,,fee schedule,Pays 100% Medicare OPPS,39.44,130,,,fee schedule,Pays 130% Medicare OPPS,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.21,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,59.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,30.6,100,,,fee schedule,Pays 100% Medicare OPPS,27.54,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,30.34,100,,,fee schedule,Pays 100% Medicare OPPS,39.44,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,30.6,100,,,fee schedule,Pays 100% Medicare OPPS,27.54,153,
Measures how much air is in the lungs after taking a deep breath,5594360,CDM,460,RC,94726,HCPCS,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,320.23,130,,,fee schedule,Pays 130% Medicare OPPS,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,242.49,102,,,fee schedule,Pays 102% Medicare OPPS,153,90,,,percent of total billed charges,90% of total billed charges,59.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,213.96,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,246.33,100,,,fee schedule,Pays 100% Medicare OPPS,320.23,130,,,fee schedule,Pays 130% Medicare OPPS,144.5,85,,,percent of total billed charges,85% of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,34.63,320.23,
FORCEP HOT BIOPSY DISP. FD210U,7905047,CDM,272,RC,,,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,153,90,,,percent of total billed charges,90% of total billed charges,59.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,153,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,144.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,34.63,153,
THORACENTESIS KIT 30-CE1CO,7905679,CDM,270,RC,,,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,153,90,,,percent of total billed charges,90% of total billed charges,59.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,153,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,144.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,34.63,153,
AIRWAY NASOPHARYNGEAL,7905759,CDM,270,RC,,,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,153,90,,,percent of total billed charges,90% of total billed charges,59.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,153,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,144.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,34.63,153,
UTERINE MANIPULATOR,7950116,CDM,270,RC,,,Outpatient,,,170,136,,144.5,85,,,percent of total billed charges,85% of total billed charges,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,42.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,153,90,,,percent of total billed charges,90% of total billed charges,59.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,116.79,68.7,,,percent of total billed charges,68.7% of total billed charges,136,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,153,90,,,fee schedule,Pays 90% Medicare OPPS,98.6,58,,,percent of total billed charges,58% of total billed charges,34.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,144.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,34.63,153,
ULTRASLING II LG (INCLUDES FRT & ADJ),7905281,CDM,274,RC,L3670,HCPCS,Both,,,173.44,138.75,,147.42,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,35.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,156.1,90,,,percent of total billed charges,90% of total billed charges,60.7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,119.15,68.7,,,percent of total billed charges,68.7% of total billed charges,138.75,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,100.6,58,,,percent of total billed charges,58% of total billed charges,35.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,147.42,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,35.33,156.1,
ULTRASLING III MED (INCLUDES FRT & ADJ),7905302,CDM,274,RC,L3670,HCPCS,Both,,,173.44,138.75,,147.42,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,35.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,156.1,90,,,percent of total billed charges,90% of total billed charges,60.7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,119.15,68.7,,,percent of total billed charges,68.7% of total billed charges,138.75,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,100.6,58,,,percent of total billed charges,58% of total billed charges,35.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,147.42,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,35.33,156.1,
ULTRASLING III LG (INCLUDES FRT & ADJ),7905303,CDM,274,RC,L3670,HCPCS,Both,,,173.44,138.75,,147.42,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,35.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,156.1,90,,,percent of total billed charges,90% of total billed charges,60.7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,119.15,68.7,,,percent of total billed charges,68.7% of total billed charges,138.75,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,100.6,58,,,percent of total billed charges,58% of total billed charges,35.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,147.42,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,35.33,156.1,
ULTRASLING III XL(INCLUDES FRT & ADJ),7905304,CDM,274,RC,L3670,HCPCS,Both,,,173.44,138.75,,147.42,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,35.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,156.1,90,,,percent of total billed charges,90% of total billed charges,60.7,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,119.15,68.7,,,percent of total billed charges,68.7% of total billed charges,138.75,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,100.6,58,,,percent of total billed charges,58% of total billed charges,35.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,147.42,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,35.33,156.1,
NON-FORM TOPICAL TOP,2600095,CDM,637,RC,,,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,157.5,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,148.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,35.65,157.5,
NON-FORMULARY INJ,2600097,CDM,250,RC,,,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,157.5,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,148.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,35.65,157.5,
TOBRADEX (TOBRAMYCIN/DEX) OPHT DROP,2600336,CDM,250,RC,,,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,157.5,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,148.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,35.65,157.5,
CETACAINE (BENZO/TETRACAINE) SPRAY,2600409,CDM,637,RC,,,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,157.5,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,148.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,35.65,157.5,
DERMABOND TOPICAL MIS,2600552,CDM,270,RC,,,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,157.5,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,148.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,35.65,157.5,
MEFOXIN INJ (CEFOXITIN) 1GM,2601037,CDM,636,RC,J0694,HCPCS,Both,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,6.39,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,157.5,90,,,percent of total billed charges,90% of total billed charges,6.65,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,157.5,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,6.39,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,148.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.39,157.5,
NON-FORM BOTTLE LIQ,2602230,CDM,637,RC,,,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,157.5,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,148.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,35.65,157.5,
GENTAMICIN FOR IRRIGATION 100 MG,2602232,CDM,636,RC,J1580,HCPCS,Both,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3.2,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,157.5,90,,,percent of total billed charges,90% of total billed charges,3.33,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,157.5,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,3.2,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,148.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.2,157.5,
NULYTELY CHERRY(PGE-3350 + LYTES):4000ML,2605165,CDM,250,RC,,,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,157.5,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,148.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,35.65,157.5,
LIPOSYN 20% (LIPID EMULSION)500 ML,2611006,CDM,250,RC,,,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,43.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,157.5,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,148.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,35.65,157.5,
CRYSTALS KNEE FLUID,3000064,CDM,309,RC,89060,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,7.33,100,,,fee schedule,Pays 100% Medicare OPPS,7.33,100,,,fee schedule,Pays 100% Medicare OPPS,7.33,100,,,fee schedule,Pays 100% Medicare OPPS,9.52,130,,,fee schedule,Pays 130% Medicare OPPS,10.82,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,7.47,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,11.25,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,7.33,100,,,fee schedule,Pays 100% Medicare OPPS,6.59,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,10.82,120.37,,,fee schedule,120.37% of custom fee schedule,7.33,100,,,fee schedule,Pays 100% Medicare OPPS,9.52,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,7.33,100,,,fee schedule,Pays 100% Medicare OPPS,6.59,157.5,
DRUG SCREEN CONFIRM Ua ea,3000088,CDM,301,RC,80375,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,21.97,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,157.5,90,,,percent of total billed charges,90% of total billed charges,22.85,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,101.5,58,,,percent of total billed charges,58% of total billed charges,21.97,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,148.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,21.97,157.5,
.FLUORESCENT NONINF TITER,3000114,CDM,302,RC,86256,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,,,fee schedule,Pays 130% Medicare OPPS,18.25,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.29,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,18.98,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,10.84,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,18.25,120.37,,,fee schedule,120.37% of custom fee schedule,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,10.84,157.5,
Test to predict likelihood of gestational diabetes,3000137,CDM,301,RC,82951,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,12.87,100,,,fee schedule,Pays 100% Medicare OPPS,12.87,100,,,fee schedule,Pays 100% Medicare OPPS,12.87,100,,,fee schedule,Pays 100% Medicare OPPS,16.73,130,,,fee schedule,Pays 130% Medicare OPPS,19.49,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.12,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,20.27,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,12.87,100,,,fee schedule,Pays 100% Medicare OPPS,11.58,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,19.49,120.37,,,fee schedule,120.37% of custom fee schedule,12.87,100,,,fee schedule,Pays 100% Medicare OPPS,16.73,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,12.87,100,,,fee schedule,Pays 100% Medicare OPPS,11.58,157.5,
Test to determine levels of immunoglobulins in the blood,3000159,CDM,301,RC,82784,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,12.09,130,,,fee schedule,Pays 130% Medicare OPPS,14.07,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.48,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,14.63,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,8.37,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,14.07,120.37,,,fee schedule,120.37% of custom fee schedule,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,12.09,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,8.37,157.5,
Test to determine levels of immunoglobulins in the blood,3000161,CDM,301,RC,82784,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,12.09,130,,,fee schedule,Pays 130% Medicare OPPS,14.07,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.48,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,14.63,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,8.37,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,14.07,120.37,,,fee schedule,120.37% of custom fee schedule,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,12.09,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,8.37,157.5,
".IMMUNOASSAY QUANT,NOT SPE",3000164,CDM,301,RC,83520,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,130,,,fee schedule,Pays 130% Medicare OPPS,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.61,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,20.38,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,15.54,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,15.54,157.5,
RH ANTIBODY TITER,3000257,CDM,302,RC,86256,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,,,fee schedule,Pays 130% Medicare OPPS,18.25,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.29,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,18.98,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,10.84,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,18.25,120.37,,,fee schedule,120.37% of custom fee schedule,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,10.84,157.5,
SGOT,3000281,CDM,301,RC,84450,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,6.73,130,,,fee schedule,Pays 130% Medicare OPPS,7.64,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.28,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,7.95,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,4.66,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,7.64,120.37,,,fee schedule,120.37% of custom fee schedule,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,6.73,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,4.66,157.5,
Blood test to evaluate liver function,3000282,CDM,301,RC,84460,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,5.3,100,,,fee schedule,Pays 100% Medicare OPPS,5.3,100,,,fee schedule,Pays 100% Medicare OPPS,5.3,100,,,fee schedule,Pays 100% Medicare OPPS,6.89,130,,,fee schedule,Pays 130% Medicare OPPS,7.64,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.4,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,7.95,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,5.3,100,,,fee schedule,Pays 100% Medicare OPPS,4.77,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,7.64,120.37,,,fee schedule,120.37% of custom fee schedule,5.3,100,,,fee schedule,Pays 100% Medicare OPPS,6.89,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,5.3,100,,,fee schedule,Pays 100% Medicare OPPS,4.77,157.5,
.OJ AUTOABS,3000622,CDM,301,RC,86235,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.28,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,28.23,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,157.5,
.SRP AUTOABS,3000623,CDM,301,RC,86235,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.28,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,28.23,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,157.5,
3RD LACOSAMIDE/VIMPAT,3000661,CDM,306,RC,80299,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.01,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,18.95,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,157.5,
.ALDOSTERONE,3000671,CDM,302,RC,82088,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,40.75,100,,,fee schedule,Pays 100% Medicare OPPS,40.75,100,,,fee schedule,Pays 100% Medicare OPPS,40.75,100,,,fee schedule,Pays 100% Medicare OPPS,52.97,130,,,fee schedule,Pays 130% Medicare OPPS,61.69,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,41.56,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,64.15,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,40.75,100,,,fee schedule,Pays 100% Medicare OPPS,36.67,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,61.69,120.37,,,fee schedule,120.37% of custom fee schedule,40.75,100,,,fee schedule,Pays 100% Medicare OPPS,52.97,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,40.75,100,,,fee schedule,Pays 100% Medicare OPPS,36.67,157.5,
Manual urinalysis test with examination with or without using microscope,3000724,CDM,300,RC,81001,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,3.17,100,,,fee schedule,Pays 100% Medicare OPPS,3.17,100,,,fee schedule,Pays 100% Medicare OPPS,3.17,100,,,fee schedule,Pays 100% Medicare OPPS,4.12,130,,,fee schedule,Pays 130% Medicare OPPS,4.8,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3.23,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,4.99,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,3.17,100,,,fee schedule,Pays 100% Medicare OPPS,2.85,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,4.8,120.37,,,fee schedule,120.37% of custom fee schedule,3.17,100,,,fee schedule,Pays 100% Medicare OPPS,4.12,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,3.17,100,,,fee schedule,Pays 100% Medicare OPPS,2.85,157.5,
.ASO (STREPTOZYME) (EFCH),3000809,CDM,302,RC,86060,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,7.3,100,,,fee schedule,Pays 100% Medicare OPPS,7.3,100,,,fee schedule,Pays 100% Medicare OPPS,7.3,100,,,fee schedule,Pays 100% Medicare OPPS,9.49,130,,,fee schedule,Pays 130% Medicare OPPS,10.58,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,7.44,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,11,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,7.3,100,,,fee schedule,Pays 100% Medicare OPPS,6.57,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,10.58,120.37,,,fee schedule,120.37% of custom fee schedule,7.3,100,,,fee schedule,Pays 100% Medicare OPPS,9.49,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,7.3,100,,,fee schedule,Pays 100% Medicare OPPS,6.57,157.5,
NICOTINE,3080323,CDM,301,RC,80323,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,45.44,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,157.5,90,,,percent of total billed charges,90% of total billed charges,47.26,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,101.5,58,,,percent of total billed charges,58% of total billed charges,45.44,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,148.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,45.44,157.5,
"BILIRUBIN, TOTAL",3082247,CDM,301,RC,82247,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,5.01,100,,,fee schedule,Pays 100% Medicare OPPS,5.01,100,,,fee schedule,Pays 100% Medicare OPPS,5.01,100,,,fee schedule,Pays 100% Medicare OPPS,6.52,130,,,fee schedule,Pays 130% Medicare OPPS,7.61,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.12,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,7.91,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,5.01,100,,,fee schedule,Pays 100% Medicare OPPS,4.51,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,7.61,120.37,,,fee schedule,120.37% of custom fee schedule,5.01,100,,,fee schedule,Pays 100% Medicare OPPS,6.52,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,5.01,100,,,fee schedule,Pays 100% Medicare OPPS,4.51,157.5,
Measurement of direct bilirubin,3082248,CDM,301,RC,82248,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,5.01,100,,,fee schedule,Pays 100% Medicare OPPS,5.01,100,,,fee schedule,Pays 100% Medicare OPPS,5.01,100,,,fee schedule,Pays 100% Medicare OPPS,6.52,130,,,fee schedule,Pays 130% Medicare OPPS,7.61,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.12,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,7.91,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,5.01,100,,,fee schedule,Pays 100% Medicare OPPS,4.51,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,7.61,120.37,,,fee schedule,120.37% of custom fee schedule,5.01,100,,,fee schedule,Pays 100% Medicare OPPS,6.52,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,5.01,100,,,fee schedule,Pays 100% Medicare OPPS,4.51,157.5,
CHOLESTEROL,3082465,CDM,301,RC,82465,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,4.34,100,,,fee schedule,Pays 100% Medicare OPPS,4.34,100,,,fee schedule,Pays 100% Medicare OPPS,4.34,100,,,fee schedule,Pays 100% Medicare OPPS,5.65,130,,,fee schedule,Pays 130% Medicare OPPS,6.58,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.43,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,6.85,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,4.34,100,,,fee schedule,Pays 100% Medicare OPPS,3.91,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,6.58,120.37,,,fee schedule,120.37% of custom fee schedule,4.34,100,,,fee schedule,Pays 100% Medicare OPPS,5.65,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,4.34,100,,,fee schedule,Pays 100% Medicare OPPS,3.91,157.5,
Test to predict likelihood of gestational diabetes,3082951,CDM,301,RC,82951,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,12.87,100,,,fee schedule,Pays 100% Medicare OPPS,12.87,100,,,fee schedule,Pays 100% Medicare OPPS,12.87,100,,,fee schedule,Pays 100% Medicare OPPS,16.73,130,,,fee schedule,Pays 130% Medicare OPPS,19.49,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.12,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,20.27,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,12.87,100,,,fee schedule,Pays 100% Medicare OPPS,11.58,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,19.49,120.37,,,fee schedule,120.37% of custom fee schedule,12.87,100,,,fee schedule,Pays 100% Medicare OPPS,16.73,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,12.87,100,,,fee schedule,Pays 100% Medicare OPPS,11.58,157.5,
GGT,3082977,CDM,301,RC,82977,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,7.2,100,,,fee schedule,Pays 100% Medicare OPPS,7.2,100,,,fee schedule,Pays 100% Medicare OPPS,7.2,100,,,fee schedule,Pays 100% Medicare OPPS,9.36,130,,,fee schedule,Pays 130% Medicare OPPS,7.64,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,7.34,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,7.95,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,7.2,100,,,fee schedule,Pays 100% Medicare OPPS,6.48,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,7.64,120.37,,,fee schedule,120.37% of custom fee schedule,7.2,100,,,fee schedule,Pays 100% Medicare OPPS,9.36,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,7.2,100,,,fee schedule,Pays 100% Medicare OPPS,6.48,157.5,
TRIGLYCERIDES LEVEL,3084478,CDM,301,RC,84478,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,5.74,100,,,fee schedule,Pays 100% Medicare OPPS,5.74,100,,,fee schedule,Pays 100% Medicare OPPS,5.74,100,,,fee schedule,Pays 100% Medicare OPPS,7.46,130,,,fee schedule,Pays 130% Medicare OPPS,7.64,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.85,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,7.95,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,5.74,100,,,fee schedule,Pays 100% Medicare OPPS,5.16,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,7.64,120.37,,,fee schedule,120.37% of custom fee schedule,5.74,100,,,fee schedule,Pays 100% Medicare OPPS,7.46,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,5.74,100,,,fee schedule,Pays 100% Medicare OPPS,5.16,157.5,
ASO (STREPTOZYME),3086063,CDM,302,RC,86060,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,7.3,100,,,fee schedule,Pays 100% Medicare OPPS,7.3,100,,,fee schedule,Pays 100% Medicare OPPS,7.3,100,,,fee schedule,Pays 100% Medicare OPPS,9.49,130,,,fee schedule,Pays 130% Medicare OPPS,10.58,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,7.44,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,11,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,7.3,100,,,fee schedule,Pays 100% Medicare OPPS,6.57,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,10.58,120.37,,,fee schedule,120.37% of custom fee schedule,7.3,100,,,fee schedule,Pays 100% Medicare OPPS,9.49,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,7.3,100,,,fee schedule,Pays 100% Medicare OPPS,6.57,157.5,
MONO TEST,3086308,CDM,302,RC,86308,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,6.73,130,,,fee schedule,Pays 130% Medicare OPPS,7.84,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.28,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,8.15,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,4.66,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,7.84,120.37,,,fee schedule,120.37% of custom fee schedule,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,6.73,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,5.18,100,,,fee schedule,Pays 100% Medicare OPPS,4.66,157.5,
.EBV (EB VIRUS),3086664,CDM,302,RC,86664,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,15.29,100,,,fee schedule,Pays 100% Medicare OPPS,15.29,100,,,fee schedule,Pays 100% Medicare OPPS,15.29,100,,,fee schedule,Pays 100% Medicare OPPS,19.87,130,,,fee schedule,Pays 130% Medicare OPPS,23.16,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.59,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,24.08,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,15.29,100,,,fee schedule,Pays 100% Medicare OPPS,13.76,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,23.16,120.37,,,fee schedule,120.37% of custom fee schedule,15.29,100,,,fee schedule,Pays 100% Medicare OPPS,19.87,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,15.29,100,,,fee schedule,Pays 100% Medicare OPPS,13.76,157.5,
"COOMBS, DIRECT (CRD)",3086880,CDM,300,RC,86880,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,65.72,130,,,fee schedule,Pays 130% Medicare OPPS,8.12,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,51,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,8.45,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,45,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,8.12,120.37,,,fee schedule,120.37% of custom fee schedule,50.55,100,,,fee schedule,Pays 100% Medicare OPPS,65.72,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,8.12,157.5,
O & P STAIN,3087209,CDM,306,RC,87209,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,17.98,100,,,fee schedule,Pays 100% Medicare OPPS,17.98,100,,,fee schedule,Pays 100% Medicare OPPS,17.98,100,,,fee schedule,Pays 100% Medicare OPPS,23.37,130,,,fee schedule,Pays 130% Medicare OPPS,27.2,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.33,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,28.29,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,17.98,100,,,fee schedule,Pays 100% Medicare OPPS,16.18,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,27.2,120.37,,,fee schedule,120.37% of custom fee schedule,17.98,100,,,fee schedule,Pays 100% Medicare OPPS,23.37,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,17.98,100,,,fee schedule,Pays 100% Medicare OPPS,16.18,157.5,
CRYSTALS ANY BODY FLUID,3089060,CDM,309,RC,89060,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,7.33,100,,,fee schedule,Pays 100% Medicare OPPS,7.33,100,,,fee schedule,Pays 100% Medicare OPPS,7.33,100,,,fee schedule,Pays 100% Medicare OPPS,9.52,130,,,fee schedule,Pays 130% Medicare OPPS,10.82,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,7.47,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,11.25,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,7.33,100,,,fee schedule,Pays 100% Medicare OPPS,6.59,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,10.82,120.37,,,fee schedule,120.37% of custom fee schedule,7.33,100,,,fee schedule,Pays 100% Medicare OPPS,9.52,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,7.33,100,,,fee schedule,Pays 100% Medicare OPPS,6.59,157.5,
3RD FAT STOOL QUAL,3089125,CDM,309,RC,82705,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,5.09,100,,,fee schedule,Pays 100% Medicare OPPS,5.09,100,,,fee schedule,Pays 100% Medicare OPPS,5.09,100,,,fee schedule,Pays 100% Medicare OPPS,6.63,130,,,fee schedule,Pays 130% Medicare OPPS,7.7,120.37,,,fee schedule,120.37% of custom fee schedule,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.2,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,8.01,125.18,,,fee schedule,125.18% of custom fee schedule,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,5.09,100,,,fee schedule,Pays 100% Medicare OPPS,4.58,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,7.7,120.37,,,fee schedule,120.37% of custom fee schedule,5.09,100,,,fee schedule,Pays 100% Medicare OPPS,6.63,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,5.09,100,,,fee schedule,Pays 100% Medicare OPPS,4.58,157.5,
A technique used by physical therapists to restore normal body movement patterns,5000112,CDM,420,RC,97112,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,32.81,100,,,fee schedule,Pays 100% Medicare OPPS,32.81,100,,,fee schedule,Pays 100% Medicare OPPS,32.81,100,,,fee schedule,Pays 100% Medicare OPPS,41.87,130,,,fee schedule,Pays 130% Medicare OPPS,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.47,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,32.81,100,,,fee schedule,Pays 100% Medicare OPPS,29.53,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,32.21,100,,,fee schedule,Pays 100% Medicare OPPS,41.87,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,32.81,100,,,fee schedule,Pays 100% Medicare OPPS,29.53,157.5,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",5007110,CDM,420,RC,97110,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,28.35,100,,,fee schedule,Pays 100% Medicare OPPS,28.35,100,,,fee schedule,Pays 100% Medicare OPPS,28.35,100,,,fee schedule,Pays 100% Medicare OPPS,36.57,130,,,fee schedule,Pays 130% Medicare OPPS,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.92,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,28.35,100,,,fee schedule,Pays 100% Medicare OPPS,25.52,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.13,100,,,fee schedule,Pays 100% Medicare OPPS,36.57,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,28.35,100,,,fee schedule,Pays 100% Medicare OPPS,25.52,157.5,
A technique used by physical therapists to restore normal body movement patterns,5007112,CDM,420,RC,97112,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,32.81,100,,,fee schedule,Pays 100% Medicare OPPS,32.81,100,,,fee schedule,Pays 100% Medicare OPPS,32.81,100,,,fee schedule,Pays 100% Medicare OPPS,41.87,130,,,fee schedule,Pays 130% Medicare OPPS,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.47,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,32.81,100,,,fee schedule,Pays 100% Medicare OPPS,29.53,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,32.21,100,,,fee schedule,Pays 100% Medicare OPPS,41.87,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,32.81,100,,,fee schedule,Pays 100% Medicare OPPS,29.53,157.5,
A type of physical therapy,5007116,CDM,420,RC,97116,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,28.35,100,,,fee schedule,Pays 100% Medicare OPPS,28.35,100,,,fee schedule,Pays 100% Medicare OPPS,28.35,100,,,fee schedule,Pays 100% Medicare OPPS,36.57,130,,,fee schedule,Pays 130% Medicare OPPS,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.92,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,28.35,100,,,fee schedule,Pays 100% Medicare OPPS,25.52,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.13,100,,,fee schedule,Pays 100% Medicare OPPS,36.57,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,28.35,100,,,fee schedule,Pays 100% Medicare OPPS,25.52,157.5,
Manipulation of 1 or more regions of the body,5007140,CDM,420,RC,97140,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,26.14,100,,,fee schedule,Pays 100% Medicare OPPS,26.14,100,,,fee schedule,Pays 100% Medicare OPPS,26.14,100,,,fee schedule,Pays 100% Medicare OPPS,33.75,130,,,fee schedule,Pays 130% Medicare OPPS,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,26.66,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,26.14,100,,,fee schedule,Pays 100% Medicare OPPS,23.53,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.96,100,,,fee schedule,Pays 100% Medicare OPPS,33.75,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,26.14,100,,,fee schedule,Pays 100% Medicare OPPS,23.53,157.5,
A technique used by physical therapists to restore normal body movement patterns,5009711,CDM,420,RC,97112,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,32.81,100,,,fee schedule,Pays 100% Medicare OPPS,32.81,100,,,fee schedule,Pays 100% Medicare OPPS,32.81,100,,,fee schedule,Pays 100% Medicare OPPS,41.87,130,,,fee schedule,Pays 130% Medicare OPPS,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.47,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,32.81,100,,,fee schedule,Pays 100% Medicare OPPS,29.53,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,32.21,100,,,fee schedule,Pays 100% Medicare OPPS,41.87,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,32.81,100,,,fee schedule,Pays 100% Medicare OPPS,29.53,157.5,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",5097110,CDM,420,RC,97110,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,28.35,100,,,fee schedule,Pays 100% Medicare OPPS,28.35,100,,,fee schedule,Pays 100% Medicare OPPS,28.35,100,,,fee schedule,Pays 100% Medicare OPPS,36.57,130,,,fee schedule,Pays 130% Medicare OPPS,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.92,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,28.35,100,,,fee schedule,Pays 100% Medicare OPPS,25.52,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.13,100,,,fee schedule,Pays 100% Medicare OPPS,36.57,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,28.35,100,,,fee schedule,Pays 100% Medicare OPPS,25.52,157.5,
A technique used by physical therapists to restore normal body movement patterns,5097112,CDM,420,RC,97112,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,32.81,100,,,fee schedule,Pays 100% Medicare OPPS,32.81,100,,,fee schedule,Pays 100% Medicare OPPS,32.81,100,,,fee schedule,Pays 100% Medicare OPPS,41.87,130,,,fee schedule,Pays 130% Medicare OPPS,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.47,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,32.81,100,,,fee schedule,Pays 100% Medicare OPPS,29.53,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,32.21,100,,,fee schedule,Pays 100% Medicare OPPS,41.87,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,32.81,100,,,fee schedule,Pays 100% Medicare OPPS,29.53,157.5,
A type of physical therapy,5097116,CDM,420,RC,97116,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,28.35,100,,,fee schedule,Pays 100% Medicare OPPS,28.35,100,,,fee schedule,Pays 100% Medicare OPPS,28.35,100,,,fee schedule,Pays 100% Medicare OPPS,36.57,130,,,fee schedule,Pays 130% Medicare OPPS,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.92,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,28.35,100,,,fee schedule,Pays 100% Medicare OPPS,25.52,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.13,100,,,fee schedule,Pays 100% Medicare OPPS,36.57,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,28.35,100,,,fee schedule,Pays 100% Medicare OPPS,25.52,157.5,
Manipulation of 1 or more regions of the body,5097140,CDM,420,RC,97140,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,26.14,100,,,fee schedule,Pays 100% Medicare OPPS,26.14,100,,,fee schedule,Pays 100% Medicare OPPS,26.14,100,,,fee schedule,Pays 100% Medicare OPPS,33.75,130,,,fee schedule,Pays 130% Medicare OPPS,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,26.66,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,26.14,100,,,fee schedule,Pays 100% Medicare OPPS,23.53,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.96,100,,,fee schedule,Pays 100% Medicare OPPS,33.75,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,26.14,100,,,fee schedule,Pays 100% Medicare OPPS,23.53,157.5,
PT WHEELCHAIR MNGT TRAINI (PER 15 MINS),5097542,CDM,420,RC,97542,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,30.6,100,,,fee schedule,Pays 100% Medicare OPPS,30.6,100,,,fee schedule,Pays 100% Medicare OPPS,30.6,100,,,fee schedule,Pays 100% Medicare OPPS,39.44,130,,,fee schedule,Pays 130% Medicare OPPS,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.21,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,30.6,100,,,fee schedule,Pays 100% Medicare OPPS,27.54,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,30.34,100,,,fee schedule,Pays 100% Medicare OPPS,39.44,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,30.6,100,,,fee schedule,Pays 100% Medicare OPPS,27.54,157.5,
Occupational therapy,5129132,CDM,430,RC,97535,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,31.39,100,,,fee schedule,Pays 100% Medicare OPPS,31.39,100,,,fee schedule,Pays 100% Medicare OPPS,31.39,100,,,fee schedule,Pays 100% Medicare OPPS,40.44,130,,,fee schedule,Pays 130% Medicare OPPS,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,32.02,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,31.39,100,,,fee schedule,Pays 100% Medicare OPPS,28.25,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,31.11,100,,,fee schedule,Pays 100% Medicare OPPS,40.44,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,31.39,100,,,fee schedule,Pays 100% Medicare OPPS,28.25,157.5,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",5197110,CDM,430,RC,97110,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,28.35,100,,,fee schedule,Pays 100% Medicare OPPS,28.35,100,,,fee schedule,Pays 100% Medicare OPPS,28.35,100,,,fee schedule,Pays 100% Medicare OPPS,36.57,130,,,fee schedule,Pays 130% Medicare OPPS,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.92,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,28.35,100,,,fee schedule,Pays 100% Medicare OPPS,25.52,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,28.13,100,,,fee schedule,Pays 100% Medicare OPPS,36.57,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,28.35,100,,,fee schedule,Pays 100% Medicare OPPS,25.52,157.5,
A technique used by physical therapists to restore normal body movement patterns,5197112,CDM,430,RC,97112,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,32.81,100,,,fee schedule,Pays 100% Medicare OPPS,32.81,100,,,fee schedule,Pays 100% Medicare OPPS,32.81,100,,,fee schedule,Pays 100% Medicare OPPS,41.87,130,,,fee schedule,Pays 130% Medicare OPPS,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,33.47,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,32.81,100,,,fee schedule,Pays 100% Medicare OPPS,29.53,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,32.21,100,,,fee schedule,Pays 100% Medicare OPPS,41.87,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,32.81,100,,,fee schedule,Pays 100% Medicare OPPS,29.53,157.5,
Manipulation of 1 or more regions of the body,5197140,CDM,430,RC,97140,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,26.14,100,,,fee schedule,Pays 100% Medicare OPPS,26.14,100,,,fee schedule,Pays 100% Medicare OPPS,26.14,100,,,fee schedule,Pays 100% Medicare OPPS,33.75,130,,,fee schedule,Pays 130% Medicare OPPS,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,26.66,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,26.14,100,,,fee schedule,Pays 100% Medicare OPPS,23.53,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,25.96,100,,,fee schedule,Pays 100% Medicare OPPS,33.75,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,26.14,100,,,fee schedule,Pays 100% Medicare OPPS,23.53,157.5,
"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",5197530,CDM,430,RC,97530,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,35.29,100,,,fee schedule,Pays 100% Medicare OPPS,35.29,100,,,fee schedule,Pays 100% Medicare OPPS,35.29,100,,,fee schedule,Pays 100% Medicare OPPS,45.44,130,,,fee schedule,Pays 130% Medicare OPPS,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,35.29,100,,,fee schedule,Pays 100% Medicare OPPS,31.76,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,34.95,100,,,fee schedule,Pays 100% Medicare OPPS,45.44,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,35.29,100,,,fee schedule,Pays 100% Medicare OPPS,31.76,157.5,
OT WHEELCHAIR MNGT TRAING (PER 15 MINS),5197542,CDM,430,RC,97542,HCPCS,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,30.6,100,,,fee schedule,Pays 100% Medicare OPPS,30.6,100,,,fee schedule,Pays 100% Medicare OPPS,30.6,100,,,fee schedule,Pays 100% Medicare OPPS,39.44,130,,,fee schedule,Pays 130% Medicare OPPS,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.21,102,,,fee schedule,Pays 102% Medicare OPPS,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,30.6,100,,,fee schedule,Pays 100% Medicare OPPS,27.54,90,,,fee schedule,Pays 90% Medicare OPPS,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,30.34,100,,,fee schedule,Pays 100% Medicare OPPS,39.44,130,,,fee schedule,Pays 130% Medicare OPPS,148.75,85,,,percent of total billed charges,85% of total billed charges,30.6,100,,,fee schedule,Pays 100% Medicare OPPS,27.54,157.5,
**DO NOT USE**,7905327,CDM,272,RC,,,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,148.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,35.65,157.5,
HERNIA BARD MESH 3 X 6 0112680,7950233,CDM,278,RC,C1781,HCPCS,Both,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,148.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,35.65,157.5,
CATH KUMAR CHOLANGIOGRAPHY CC-019,7950257,CDM,272,RC,,,Outpatient,,,175,140,,148.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,157.5,90,,,percent of total billed charges,90% of total billed charges,61.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,120.23,68.7,,,percent of total billed charges,68.7% of total billed charges,140,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,101.5,58,,,percent of total billed charges,58% of total billed charges,35.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,148.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,35.65,157.5,
ORTHOPEDIC W TRAY,7901201,CDM,272,RC,,,Outpatient,,,179,143.2,,152.15,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,101.14,56.5,,,percent of total billed charges,56.5 percent of total billed charges,101.14,56.5,,,percent of total billed charges,56.5 percent of total billed charges,101.14,56.5,,,percent of total billed charges,56.5 percent of total billed charges,101.14,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,161.1,90,,,percent of total billed charges,90% of total billed charges,62.65,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,122.97,68.7,,,percent of total billed charges,68.7% of total billed charges,143.2,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,103.82,58,,,percent of total billed charges,58% of total billed charges,36.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,152.15,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,36.46,161.1,
ADMIN 3RD PFIZER DOSE COVID19 VACCINE,2611118,CDM,771,RC,0003A,HCPCS,Outpatient,,,180,144,,153,85,,,percent of total billed charges,85% of total billed charges,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,36.67,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,101.7,56.5,,,percent of total billed charges,56.5 percent of total billed charges,101.7,56.5,,,percent of total billed charges,56.5 percent of total billed charges,101.7,56.5,,,percent of total billed charges,56.5 percent of total billed charges,101.7,56.5,,,percent of total billed charges,56.5 percent of total billed charges,35.88,102,,,fee schedule,Pays 102% Medicare OPPS,162,90,,,percent of total billed charges,90% of total billed charges,63,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,123.66,68.7,,,percent of total billed charges,68.7% of total billed charges,144,80,,,percent of total billed charges,80 percent of total billed charges,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,31.66,90,,,fee schedule,Pays 90% Medicare OPPS,104.4,58,,,percent of total billed charges,58% of total billed charges,36.67,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,35.18,100,,,fee schedule,Pays 100% Medicare OPPS,31.66,162,
CHEST TUBE INSERTION TRAY MNS2250,7950340,CDM,270,RC,,,Outpatient,,,180.9,144.72,,153.77,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.21,56.5,,,percent of total billed charges,56.5 percent of total billed charges,102.21,56.5,,,percent of total billed charges,56.5 percent of total billed charges,102.21,56.5,,,percent of total billed charges,56.5 percent of total billed charges,102.21,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,162.81,90,,,percent of total billed charges,90% of total billed charges,63.32,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,124.28,68.7,,,percent of total billed charges,68.7% of total billed charges,144.72,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,104.92,58,,,percent of total billed charges,58% of total billed charges,36.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,153.77,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,36.85,162.81,
BLAKE DRAIN 10 MM 2214,7905737,CDM,270,RC,,,Outpatient,,,181,144.8,,153.85,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,36.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.27,56.5,,,percent of total billed charges,56.5 percent of total billed charges,102.27,56.5,,,percent of total billed charges,56.5 percent of total billed charges,102.27,56.5,,,percent of total billed charges,56.5 percent of total billed charges,102.27,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,162.9,90,,,percent of total billed charges,90% of total billed charges,63.35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,124.35,68.7,,,percent of total billed charges,68.7% of total billed charges,144.8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,104.98,58,,,percent of total billed charges,58% of total billed charges,36.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,153.85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,36.87,162.9,
LARYNGOSCOPE VIDEO LOPRO S3,1570848,CDM,272,RC,,,Outpatient,,,185,148,,157.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,37.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,166.5,90,,,percent of total billed charges,90% of total billed charges,64.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,127.1,68.7,,,percent of total billed charges,68.7% of total billed charges,148,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,107.3,58,,,percent of total billed charges,58% of total billed charges,37.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,157.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,37.68,166.5,
LARYNGOSCOPE VIDEO LOPRO S4,1570849,CDM,272,RC,,,Outpatient,,,185,148,,157.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,37.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,166.5,90,,,percent of total billed charges,90% of total billed charges,64.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,127.1,68.7,,,percent of total billed charges,68.7% of total billed charges,148,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,107.3,58,,,percent of total billed charges,58% of total billed charges,37.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,157.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,37.68,166.5,
DIFLUCAN (FLUCONAZOLE) 400MG IV PREMIX,2601296,CDM,250,RC,J1450,HCPCS,Outpatient,,,185,148,,157.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3.14,120.37,,,fee schedule,120.37% of custom fee schedule,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,166.5,90,,,percent of total billed charges,90% of total billed charges,3.27,125.18,,,fee schedule,125.18% of custom fee schedule,127.1,68.7,,,percent of total billed charges,68.7% of total billed charges,148,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,107.3,58,,,percent of total billed charges,58% of total billed charges,3.14,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,157.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,3.14,166.5,
NASAL RAPID RHINO 5.5 CM,7905956,CDM,272,RC,,,Outpatient,,,185,148,,157.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,37.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,166.5,90,,,percent of total billed charges,90% of total billed charges,64.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,127.1,68.7,,,percent of total billed charges,68.7% of total billed charges,148,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,107.3,58,,,percent of total billed charges,58% of total billed charges,37.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,157.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,37.68,166.5,
ACAPELLA VIBRATORY BLUE,7915711,CDM,270,RC,,,Outpatient,,,185,148,,157.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,37.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,166.5,90,,,percent of total billed charges,90% of total billed charges,64.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,127.1,68.7,,,percent of total billed charges,68.7% of total billed charges,148,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,107.3,58,,,percent of total billed charges,58% of total billed charges,37.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,157.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,37.68,166.5,
ACAPELLA VIBRATORY GREEN,7915712,CDM,270,RC,,,Outpatient,,,185,148,,157.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,37.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,166.5,90,,,percent of total billed charges,90% of total billed charges,64.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,127.1,68.7,,,percent of total billed charges,68.7% of total billed charges,148,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,107.3,58,,,percent of total billed charges,58% of total billed charges,37.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,157.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,37.68,166.5,
VIBRAPEP OSCILLATORY,7915714,CDM,270,RC,,,Outpatient,,,185,148,,157.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,37.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,104.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,166.5,90,,,percent of total billed charges,90% of total billed charges,64.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,127.1,68.7,,,percent of total billed charges,68.7% of total billed charges,148,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,107.3,58,,,percent of total billed charges,58% of total billed charges,37.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,157.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,37.68,166.5,
Outpatient visit of established patient not requiring a physician,2000006,CDM,761,RC,99211,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,171,90,,,percent of total billed charges,90% of total billed charges,66.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,110.2,58,,,percent of total billed charges,58% of total billed charges,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,161.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,38.7,171,
BREVITAL SODIUM (METHOHEXITAL) 500MG INJ,2600190,CDM,250,RC,,,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,171,90,,,percent of total billed charges,90% of total billed charges,66.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,110.2,58,,,percent of total billed charges,58% of total billed charges,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,161.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,38.7,171,
NFRONDEC DM (CARBINOXAMINE/PSE/DM) DROPS,2600872,CDM,637,RC,,,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,171,90,,,percent of total billed charges,90% of total billed charges,66.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,110.2,58,,,percent of total billed charges,58% of total billed charges,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,161.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,38.7,171,
ENGERIX-B (HEPATITIS B VAC) INJ : 20MCG,2601021,CDM,636,RC,90744,HCPCS,Both,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,117.06,100,,,fee schedule,Pays 100% Medicare OPPS,117.06,100,,,fee schedule,Pays 100% Medicare OPPS,117.06,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,117.35,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,66.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,117.06,100,,,fee schedule,Pays 100% Medicare OPPS,115.56,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,161.5,85,,,percent of total billed charges,85% of total billed charges,117.06,100,,,fee schedule,Pays 100% Medicare OPPS,38.7,171,
DHE-45 (DIHYDROERGOTAMINE) INJ : 1MG,2601305,CDM,636,RC,J1110,HCPCS,Both,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,69.93,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,171,90,,,percent of total billed charges,90% of total billed charges,72.73,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,110.2,58,,,percent of total billed charges,58% of total billed charges,69.93,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,161.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,69.93,171,
DURAGESIC (FENTANYL) PATCH 50MCG,2602611,CDM,637,RC,,,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,171,90,,,percent of total billed charges,90% of total billed charges,66.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,110.2,58,,,percent of total billed charges,58% of total billed charges,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,161.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,38.7,171,
NF-PREVACID (LANSOPRAZOLE) INJ : 30MG,2603053,CDM,636,RC,,,Both,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,171,90,,,percent of total billed charges,90% of total billed charges,66.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,110.2,58,,,percent of total billed charges,58% of total billed charges,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,161.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,38.7,171,
MIACALCIN (CALCITONIN) NASAL SPRAY,2605036,CDM,637,RC,,,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,171,90,,,percent of total billed charges,90% of total billed charges,66.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,110.2,58,,,percent of total billed charges,58% of total billed charges,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,161.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,38.7,171,
.GC (DNA PROBE),3000120,CDM,306,RC,87590,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,26.88,100,,,fee schedule,Pays 100% Medicare OPPS,26.88,100,,,fee schedule,Pays 100% Medicare OPPS,26.88,100,,,fee schedule,Pays 100% Medicare OPPS,34.94,130,,,fee schedule,Pays 130% Medicare OPPS,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,27.41,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,66.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,26.88,100,,,fee schedule,Pays 100% Medicare OPPS,24.19,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,26.88,100,,,fee schedule,Pays 100% Medicare OPPS,34.94,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,26.88,100,,,fee schedule,Pays 100% Medicare OPPS,24.19,171,
Test to determine levels of immunoglobulins in the blood,3000160,CDM,301,RC,82784,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,12.09,130,,,fee schedule,Pays 130% Medicare OPPS,14.07,120.37,,,fee schedule,120.37% of custom fee schedule,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.48,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,14.63,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,8.37,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,14.07,120.37,,,fee schedule,120.37% of custom fee schedule,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,12.09,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,8.37,171,
JO-1 ANTIBODY,3000177,CDM,302,RC,86235,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.28,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,28.23,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,171,
MERCURY BLOOD,3000193,CDM,301,RC,83825,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,16.26,100,,,fee schedule,Pays 100% Medicare OPPS,16.26,100,,,fee schedule,Pays 100% Medicare OPPS,16.26,100,,,fee schedule,Pays 100% Medicare OPPS,21.13,130,,,fee schedule,Pays 130% Medicare OPPS,24.62,120.37,,,fee schedule,120.37% of custom fee schedule,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.58,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,25.6,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,16.26,100,,,fee schedule,Pays 100% Medicare OPPS,14.63,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,24.62,120.37,,,fee schedule,120.37% of custom fee schedule,16.26,100,,,fee schedule,Pays 100% Medicare OPPS,21.13,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,16.26,100,,,fee schedule,Pays 100% Medicare OPPS,14.63,171,
Blood test to assess for pregnancy,3000344,CDM,301,RC,84703,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,7.52,100,,,fee schedule,Pays 100% Medicare OPPS,7.52,100,,,fee schedule,Pays 100% Medicare OPPS,7.52,100,,,fee schedule,Pays 100% Medicare OPPS,9.77,130,,,fee schedule,Pays 130% Medicare OPPS,9.71,120.37,,,fee schedule,120.37% of custom fee schedule,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,7.67,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,10.1,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,7.52,100,,,fee schedule,Pays 100% Medicare OPPS,6.76,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,9.71,120.37,,,fee schedule,120.37% of custom fee schedule,7.52,100,,,fee schedule,Pays 100% Medicare OPPS,9.77,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,7.52,100,,,fee schedule,Pays 100% Medicare OPPS,6.76,171,
Chemical test of the blood to measure presence or concentration of a substance in the blood,3000364,CDM,302,RC,83516,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.76,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,16.84,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,171,
FELBAMATE,3000662,CDM,301,RC,80299,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.01,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,18.95,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,171,
POSITIVE HCV,3000734,CDM,301,RC,87522,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,130,,,fee schedule,Pays 130% Medicare OPPS,64.84,120.37,,,fee schedule,120.37% of custom fee schedule,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,43.69,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,67.43,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,38.55,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,64.84,120.37,,,fee schedule,120.37% of custom fee schedule,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,38.55,171,
Blood test to monitor vitamin D levels,3000744,CDM,301,RC,82306,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,29.6,100,,,fee schedule,Pays 100% Medicare OPPS,29.6,100,,,fee schedule,Pays 100% Medicare OPPS,29.6,100,,,fee schedule,Pays 100% Medicare OPPS,38.48,130,,,fee schedule,Pays 130% Medicare OPPS,44.8,120.37,,,fee schedule,120.37% of custom fee schedule,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,30.19,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,46.59,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,29.6,100,,,fee schedule,Pays 100% Medicare OPPS,26.64,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,44.8,120.37,,,fee schedule,120.37% of custom fee schedule,29.6,100,,,fee schedule,Pays 100% Medicare OPPS,38.48,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,29.6,100,,,fee schedule,Pays 100% Medicare OPPS,26.64,171,
Blood test to monitor vitamin D levels,3000745,CDM,301,RC,82306,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,29.6,100,,,fee schedule,Pays 100% Medicare OPPS,29.6,100,,,fee schedule,Pays 100% Medicare OPPS,29.6,100,,,fee schedule,Pays 100% Medicare OPPS,38.48,130,,,fee schedule,Pays 130% Medicare OPPS,44.8,120.37,,,fee schedule,120.37% of custom fee schedule,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,30.19,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,46.59,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,29.6,100,,,fee schedule,Pays 100% Medicare OPPS,26.64,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,44.8,120.37,,,fee schedule,120.37% of custom fee schedule,29.6,100,,,fee schedule,Pays 100% Medicare OPPS,38.48,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,29.6,100,,,fee schedule,Pays 100% Medicare OPPS,26.64,171,
Blood test to monitor vitamin D levels,3000746,CDM,301,RC,82306,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,29.6,100,,,fee schedule,Pays 100% Medicare OPPS,29.6,100,,,fee schedule,Pays 100% Medicare OPPS,29.6,100,,,fee schedule,Pays 100% Medicare OPPS,38.48,130,,,fee schedule,Pays 130% Medicare OPPS,44.8,120.37,,,fee schedule,120.37% of custom fee schedule,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,30.19,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,46.59,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,29.6,100,,,fee schedule,Pays 100% Medicare OPPS,26.64,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,44.8,120.37,,,fee schedule,120.37% of custom fee schedule,29.6,100,,,fee schedule,Pays 100% Medicare OPPS,38.48,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,29.6,100,,,fee schedule,Pays 100% Medicare OPPS,26.64,171,
Blood test to measure B-12,3000806,CDM,301,RC,82607,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,19.6,130,,,fee schedule,Pays 130% Medicare OPPS,22.81,120.37,,,fee schedule,120.37% of custom fee schedule,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.38,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,23.72,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,13.57,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,22.81,120.37,,,fee schedule,120.37% of custom fee schedule,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,19.6,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,13.57,171,
.FOLATE SERUM (EFCH),3000807,CDM,301,RC,82746,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,14.7,100,,,fee schedule,Pays 100% Medicare OPPS,14.7,100,,,fee schedule,Pays 100% Medicare OPPS,14.7,100,,,fee schedule,Pays 100% Medicare OPPS,19.11,130,,,fee schedule,Pays 130% Medicare OPPS,22.26,120.37,,,fee schedule,120.37% of custom fee schedule,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.99,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,23.15,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,14.7,100,,,fee schedule,Pays 100% Medicare OPPS,13.23,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,22.26,120.37,,,fee schedule,120.37% of custom fee schedule,14.7,100,,,fee schedule,Pays 100% Medicare OPPS,19.11,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,14.7,100,,,fee schedule,Pays 100% Medicare OPPS,13.23,171,
.RA TEST (EFCH),3000808,CDM,302,RC,86430,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,6.14,100,,,fee schedule,Pays 100% Medicare OPPS,6.14,100,,,fee schedule,Pays 100% Medicare OPPS,6.14,100,,,fee schedule,Pays 100% Medicare OPPS,7.98,130,,,fee schedule,Pays 130% Medicare OPPS,8.59,120.37,,,fee schedule,120.37% of custom fee schedule,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.26,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,8.94,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,6.14,100,,,fee schedule,Pays 100% Medicare OPPS,5.52,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,8.59,120.37,,,fee schedule,120.37% of custom fee schedule,6.14,100,,,fee schedule,Pays 100% Medicare OPPS,7.98,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,6.14,100,,,fee schedule,Pays 100% Medicare OPPS,5.52,171,
Blood test to measure B-12,3082607,CDM,301,RC,82607,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,19.6,130,,,fee schedule,Pays 130% Medicare OPPS,22.81,120.37,,,fee schedule,120.37% of custom fee schedule,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.38,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,23.72,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,13.57,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,22.81,120.37,,,fee schedule,120.37% of custom fee schedule,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,19.6,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,13.57,171,
B-12 BINDING CAPACITY,3082608,CDM,301,RC,82608,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,14.32,100,,,fee schedule,Pays 100% Medicare OPPS,14.32,100,,,fee schedule,Pays 100% Medicare OPPS,14.32,100,,,fee schedule,Pays 100% Medicare OPPS,18.61,130,,,fee schedule,Pays 130% Medicare OPPS,21.68,120.37,,,fee schedule,120.37% of custom fee schedule,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.6,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,22.54,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,14.32,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,21.68,120.37,,,fee schedule,120.37% of custom fee schedule,14.32,100,,,fee schedule,Pays 100% Medicare OPPS,18.61,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,14.32,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,171,
FOLATE SERUM,3082746,CDM,301,RC,82746,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,14.7,100,,,fee schedule,Pays 100% Medicare OPPS,14.7,100,,,fee schedule,Pays 100% Medicare OPPS,14.7,100,,,fee schedule,Pays 100% Medicare OPPS,19.11,130,,,fee schedule,Pays 130% Medicare OPPS,22.26,120.37,,,fee schedule,120.37% of custom fee schedule,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.99,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,23.15,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,14.7,100,,,fee schedule,Pays 100% Medicare OPPS,13.23,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,22.26,120.37,,,fee schedule,120.37% of custom fee schedule,14.7,100,,,fee schedule,Pays 100% Medicare OPPS,19.11,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,14.7,100,,,fee schedule,Pays 100% Medicare OPPS,13.23,171,
MAGNESIUM LEVEL,3083735,CDM,301,RC,83735,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,6.7,100,,,fee schedule,Pays 100% Medicare OPPS,6.7,100,,,fee schedule,Pays 100% Medicare OPPS,6.7,100,,,fee schedule,Pays 100% Medicare OPPS,8.71,130,,,fee schedule,Pays 130% Medicare OPPS,10.14,120.37,,,fee schedule,120.37% of custom fee schedule,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.83,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,10.54,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,6.7,100,,,fee schedule,Pays 100% Medicare OPPS,6.03,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,10.14,120.37,,,fee schedule,120.37% of custom fee schedule,6.7,100,,,fee schedule,Pays 100% Medicare OPPS,8.71,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,6.7,100,,,fee schedule,Pays 100% Medicare OPPS,6.03,171,
Urine pregnancy test,3084703,CDM,301,RC,81025,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.19,130,,,fee schedule,Pays 130% Medicare OPPS,9.58,120.37,,,fee schedule,120.37% of custom fee schedule,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.78,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,9.96,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,7.74,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,9.58,120.37,,,fee schedule,120.37% of custom fee schedule,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.19,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,7.74,171,
"Complete blood count, automated",3085027,CDM,305,RC,85027,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,8.41,130,,,fee schedule,Pays 130% Medicare OPPS,9.8,120.37,,,fee schedule,120.37% of custom fee schedule,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.59,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,10.19,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,5.82,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,9.8,120.37,,,fee schedule,120.37% of custom fee schedule,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,8.41,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,5.82,171,
"Complete blood count, automated",3085028,CDM,300,RC,85027,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,8.41,130,,,fee schedule,Pays 130% Medicare OPPS,9.8,120.37,,,fee schedule,120.37% of custom fee schedule,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.59,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,10.19,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,5.82,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,9.8,120.37,,,fee schedule,120.37% of custom fee schedule,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,8.41,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,6.47,100,,,fee schedule,Pays 100% Medicare OPPS,5.82,171,
3RD MYLELIN ANTIBODY IGG,3086255,CDM,301,RC,86255,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,,,fee schedule,Pays 130% Medicare OPPS,18.25,120.37,,,fee schedule,120.37% of custom fee schedule,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.29,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,18.98,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,10.84,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,18.25,120.37,,,fee schedule,120.37% of custom fee schedule,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,10.84,171,
".GEL DIFFUSION, EACH",3086331,CDM,302,RC,86331,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,15.57,130,,,fee schedule,Pays 130% Medicare OPPS,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.21,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,18.88,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,10.78,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,15.57,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,10.78,171,
RA TEST,3086430,CDM,302,RC,86431,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,5.67,100,,,fee schedule,Pays 100% Medicare OPPS,5.67,100,,,fee schedule,Pays 100% Medicare OPPS,5.67,100,,,fee schedule,Pays 100% Medicare OPPS,7.37,130,,,fee schedule,Pays 130% Medicare OPPS,8.59,120.37,,,fee schedule,120.37% of custom fee schedule,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.78,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,8.94,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,5.67,100,,,fee schedule,Pays 100% Medicare OPPS,5.1,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,8.59,120.37,,,fee schedule,120.37% of custom fee schedule,5.67,100,,,fee schedule,Pays 100% Medicare OPPS,7.37,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,5.67,100,,,fee schedule,Pays 100% Medicare OPPS,5.1,171,
3RD RA TEST BODY FLUID,3086431,CDM,302,RC,86430,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,6.14,100,,,fee schedule,Pays 100% Medicare OPPS,6.14,100,,,fee schedule,Pays 100% Medicare OPPS,6.14,100,,,fee schedule,Pays 100% Medicare OPPS,7.98,130,,,fee schedule,Pays 130% Medicare OPPS,8.59,120.37,,,fee schedule,120.37% of custom fee schedule,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.26,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,8.94,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,6.14,100,,,fee schedule,Pays 100% Medicare OPPS,5.52,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,8.59,120.37,,,fee schedule,120.37% of custom fee schedule,6.14,100,,,fee schedule,Pays 100% Medicare OPPS,7.98,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,6.14,100,,,fee schedule,Pays 100% Medicare OPPS,5.52,171,
A test used to determine which medications work on bacteria for fungi,3087186,CDM,306,RC,87186,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,8.65,100,,,fee schedule,Pays 100% Medicare OPPS,8.65,100,,,fee schedule,Pays 100% Medicare OPPS,8.65,100,,,fee schedule,Pays 100% Medicare OPPS,11.24,130,,,fee schedule,Pays 130% Medicare OPPS,13.08,120.37,,,fee schedule,120.37% of custom fee schedule,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.82,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,13.61,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,8.65,100,,,fee schedule,Pays 100% Medicare OPPS,7.78,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,13.08,120.37,,,fee schedule,120.37% of custom fee schedule,8.65,100,,,fee schedule,Pays 100% Medicare OPPS,11.24,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,8.65,100,,,fee schedule,Pays 100% Medicare OPPS,7.78,171,
.CHLAMYDIA (DNA PROBE),3087490,CDM,306,RC,87490,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,22.75,100,,,fee schedule,Pays 100% Medicare OPPS,22.75,100,,,fee schedule,Pays 100% Medicare OPPS,22.75,100,,,fee schedule,Pays 100% Medicare OPPS,29.57,130,,,fee schedule,Pays 130% Medicare OPPS,29.85,120.37,,,fee schedule,120.37% of custom fee schedule,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,23.2,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,31.04,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,22.75,100,,,fee schedule,Pays 100% Medicare OPPS,20.47,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,29.85,120.37,,,fee schedule,120.37% of custom fee schedule,22.75,100,,,fee schedule,Pays 100% Medicare OPPS,29.57,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,22.75,100,,,fee schedule,Pays 100% Medicare OPPS,20.47,171,
.CYTOGENTETICS 100-300,3088291,CDM,306,RC,88275,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,51.19,100,,,fee schedule,Pays 100% Medicare OPPS,51.19,100,,,fee schedule,Pays 100% Medicare OPPS,51.19,100,,,fee schedule,Pays 100% Medicare OPPS,66.54,130,,,fee schedule,Pays 130% Medicare OPPS,60.79,120.37,,,fee schedule,120.37% of custom fee schedule,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,52.21,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,63.22,125.18,,,fee schedule,125.18% of custom fee schedule,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,51.19,100,,,fee schedule,Pays 100% Medicare OPPS,46.07,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,60.79,120.37,,,fee schedule,120.37% of custom fee schedule,51.19,100,,,fee schedule,Pays 100% Medicare OPPS,66.54,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,51.19,100,,,fee schedule,Pays 100% Medicare OPPS,46.07,171,
"New patient office or other outpatient visit, typically 10 minutes",4000006,CDM,720,RC,99202,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,171,90,,,percent of total billed charges,90% of total billed charges,66.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,110.2,58,,,percent of total billed charges,58% of total billed charges,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,161.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,38.7,171,
MM MAMMOGRAM/TISSUE,4376098,CDM,409,RC,76098,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,434.05,100,,,fee schedule,Pays 100% Medicare OPPS,434.05,100,,,fee schedule,Pays 100% Medicare OPPS,434.05,100,,,fee schedule,Pays 100% Medicare OPPS,575.3,130,,,fee schedule,Pays 130% Medicare OPPS,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,106.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,442.73,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,66.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,434.05,100,,,fee schedule,Pays 100% Medicare OPPS,390.64,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,442.54,100,,,fee schedule,Pays 100% Medicare OPPS,575.3,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,434.05,100,,,fee schedule,Pays 100% Medicare OPPS,38.7,575.3,
"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",5000003,CDM,420,RC,97530,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,35.29,100,,,fee schedule,Pays 100% Medicare OPPS,35.29,100,,,fee schedule,Pays 100% Medicare OPPS,35.29,100,,,fee schedule,Pays 100% Medicare OPPS,45.44,130,,,fee schedule,Pays 130% Medicare OPPS,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,66.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,35.29,100,,,fee schedule,Pays 100% Medicare OPPS,31.76,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,34.95,100,,,fee schedule,Pays 100% Medicare OPPS,45.44,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,35.29,100,,,fee schedule,Pays 100% Medicare OPPS,31.76,171,
"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",5097530,CDM,420,RC,97530,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,35.29,100,,,fee schedule,Pays 100% Medicare OPPS,35.29,100,,,fee schedule,Pays 100% Medicare OPPS,35.29,100,,,fee schedule,Pays 100% Medicare OPPS,45.44,130,,,fee schedule,Pays 130% Medicare OPPS,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,66.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,35.29,100,,,fee schedule,Pays 100% Medicare OPPS,31.76,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,34.95,100,,,fee schedule,Pays 100% Medicare OPPS,45.44,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,35.29,100,,,fee schedule,Pays 100% Medicare OPPS,31.76,171,
Occupational therapy,5097535,CDM,420,RC,97535,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,31.39,100,,,fee schedule,Pays 100% Medicare OPPS,31.39,100,,,fee schedule,Pays 100% Medicare OPPS,31.39,100,,,fee schedule,Pays 100% Medicare OPPS,40.44,130,,,fee schedule,Pays 130% Medicare OPPS,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,32.02,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,66.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,31.39,100,,,fee schedule,Pays 100% Medicare OPPS,28.25,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,31.11,100,,,fee schedule,Pays 100% Medicare OPPS,40.44,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,31.39,100,,,fee schedule,Pays 100% Medicare OPPS,28.25,171,
"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",5597530,CDM,420,RC,97530,HCPCS,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,35.29,100,,,fee schedule,Pays 100% Medicare OPPS,35.29,100,,,fee schedule,Pays 100% Medicare OPPS,35.29,100,,,fee schedule,Pays 100% Medicare OPPS,45.44,130,,,fee schedule,Pays 130% Medicare OPPS,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36,102,,,fee schedule,Pays 102% Medicare OPPS,171,90,,,percent of total billed charges,90% of total billed charges,66.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,35.29,100,,,fee schedule,Pays 100% Medicare OPPS,31.76,90,,,fee schedule,Pays 90% Medicare OPPS,110.2,58,,,percent of total billed charges,58% of total billed charges,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,34.95,100,,,fee schedule,Pays 100% Medicare OPPS,45.44,130,,,fee schedule,Pays 130% Medicare OPPS,161.5,85,,,percent of total billed charges,85% of total billed charges,35.29,100,,,fee schedule,Pays 100% Medicare OPPS,31.76,171,
D & C PACK,7901195,CDM,270,RC,,,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,171,90,,,percent of total billed charges,90% of total billed charges,66.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,110.2,58,,,percent of total billed charges,58% of total billed charges,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,161.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,38.7,171,
ARTHROSCOPIC CUTTER,7901220,CDM,270,RC,,,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,171,90,,,percent of total billed charges,90% of total billed charges,66.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,110.2,58,,,percent of total billed charges,58% of total billed charges,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,161.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,38.7,171,
NASAL RAPID RHINO 7.5 CM,7905957,CDM,272,RC,,,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,171,90,,,percent of total billed charges,90% of total billed charges,66.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,110.2,58,,,percent of total billed charges,58% of total billed charges,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,161.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,38.7,171,
DRAIN CHEST OASIS DRY SUCTION,7905963,CDM,270,RC,,,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,171,90,,,percent of total billed charges,90% of total billed charges,66.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,110.2,58,,,percent of total billed charges,58% of total billed charges,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,161.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,38.7,171,
SPLINT WRIST D-RING A607XX,7907980,CDM,270,RC,,,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,171,90,,,percent of total billed charges,90% of total billed charges,66.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,110.2,58,,,percent of total billed charges,58% of total billed charges,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,161.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,38.7,171,
CROUP TENT CANOPY 0236 MES,7919429,CDM,270,RC,,,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,171,90,,,percent of total billed charges,90% of total billed charges,66.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,110.2,58,,,percent of total billed charges,58% of total billed charges,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,161.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,38.7,171,
SUTURE 5-0 CHROMIC,7950009,CDM,272,RC,,,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,171,90,,,percent of total billed charges,90% of total billed charges,66.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,110.2,58,,,percent of total billed charges,58% of total billed charges,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,161.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,38.7,171,
LINEAR STAPLER RELOAD XR60B,7950242,CDM,272,RC,,,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,171,90,,,percent of total billed charges,90% of total billed charges,66.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,110.2,58,,,percent of total billed charges,58% of total billed charges,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,161.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,38.7,171,
LINEAR STAPLER RELOAD XR60G,7950258,CDM,272,RC,,,Outpatient,,,190,152,,161.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,107.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,171,90,,,percent of total billed charges,90% of total billed charges,66.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,130.53,68.7,,,percent of total billed charges,68.7% of total billed charges,152,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,110.2,58,,,percent of total billed charges,58% of total billed charges,38.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,161.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,38.7,171,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",1090766,CDM,760,RC,96366,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.65,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,68.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,37.26,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,175.5,
SUTURE 2-0 PROLENE 8853H,1570541,CDM,272,RC,,,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,175.5,90,,,percent of total billed charges,90% of total billed charges,68.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,113.1,58,,,percent of total billed charges,58% of total billed charges,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,165.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,39.72,175.5,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",1596366,CDM,760,RC,96366,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.65,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,68.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,37.26,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,175.5,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",2090766,CDM,450,RC,96366,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.65,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,68.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,37.26,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,175.5,
ORPHENADRINE (NORFLEX) 60MG/2ML AMP,2600121,CDM,250,RC,J2360,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4.9,120.37,,,fee schedule,120.37% of custom fee schedule,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,175.5,90,,,percent of total billed charges,90% of total billed charges,5.09,125.18,,,fee schedule,125.18% of custom fee schedule,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,113.1,58,,,percent of total billed charges,58% of total billed charges,4.9,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,165.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4.9,175.5,
HURRICAINE (BENZOCAINE) 20% SPRAY,2602552,CDM,637,RC,,,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,175.5,90,,,percent of total billed charges,90% of total billed charges,68.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,113.1,58,,,percent of total billed charges,58% of total billed charges,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,165.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,39.72,175.5,
HERPES AB TY II IgM,3000008,CDM,302,RC,86790,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.13,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,20.28,125.18,,,fee schedule,125.18% of custom fee schedule,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,175.5,
HEAVY METALS (URINE),3000142,CDM,301,RC,83015,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,20.94,100,,,fee schedule,Pays 100% Medicare OPPS,20.94,100,,,fee schedule,Pays 100% Medicare OPPS,20.94,100,,,fee schedule,Pays 100% Medicare OPPS,27.22,130,,,fee schedule,Pays 130% Medicare OPPS,28.5,120.37,,,fee schedule,120.37% of custom fee schedule,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,21.35,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,29.64,125.18,,,fee schedule,125.18% of custom fee schedule,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,20.94,100,,,fee schedule,Pays 100% Medicare OPPS,18.84,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,28.5,120.37,,,fee schedule,120.37% of custom fee schedule,20.94,100,,,fee schedule,Pays 100% Medicare OPPS,27.22,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,20.94,100,,,fee schedule,Pays 100% Medicare OPPS,18.84,175.5,
HERPES AB TYP I IgM,3000147,CDM,302,RC,86790,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.13,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,20.28,125.18,,,fee schedule,125.18% of custom fee schedule,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,175.5,
Blood test to determine if antibodies exist for rubella,3000272,CDM,302,RC,86762,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.7,130,,,fee schedule,Pays 130% Medicare OPPS,17.61,120.37,,,fee schedule,120.37% of custom fee schedule,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.67,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,18.31,125.18,,,fee schedule,125.18% of custom fee schedule,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.95,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,17.61,120.37,,,fee schedule,120.37% of custom fee schedule,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.7,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.95,175.5,
Blood test to determine if antibodies exist for rubella,3000273,CDM,302,RC,86762,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.7,130,,,fee schedule,Pays 130% Medicare OPPS,17.61,120.37,,,fee schedule,120.37% of custom fee schedule,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.67,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,18.31,125.18,,,fee schedule,125.18% of custom fee schedule,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.95,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,17.61,120.37,,,fee schedule,120.37% of custom fee schedule,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.7,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.95,175.5,
Coagulation assessment blood test,3000373,CDM,305,RC,85730,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,6.01,100,,,fee schedule,Pays 100% Medicare OPPS,6.01,100,,,fee schedule,Pays 100% Medicare OPPS,6.01,100,,,fee schedule,Pays 100% Medicare OPPS,7.81,130,,,fee schedule,Pays 130% Medicare OPPS,9.08,120.37,,,fee schedule,120.37% of custom fee schedule,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.13,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,9.44,125.18,,,fee schedule,125.18% of custom fee schedule,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,6.01,100,,,fee schedule,Pays 100% Medicare OPPS,5.4,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,9.08,120.37,,,fee schedule,120.37% of custom fee schedule,6.01,100,,,fee schedule,Pays 100% Medicare OPPS,7.81,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,6.01,100,,,fee schedule,Pays 100% Medicare OPPS,5.4,175.5,
C6 COMPLEMENT,3000624,CDM,302,RC,86160,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,12,100,,,fee schedule,Pays 100% Medicare OPPS,12,100,,,fee schedule,Pays 100% Medicare OPPS,12,100,,,fee schedule,Pays 100% Medicare OPPS,15.6,130,,,fee schedule,Pays 130% Medicare OPPS,18.18,120.37,,,fee schedule,120.37% of custom fee schedule,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.24,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,18.9,125.18,,,fee schedule,125.18% of custom fee schedule,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,12,100,,,fee schedule,Pays 100% Medicare OPPS,10.8,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,18.18,120.37,,,fee schedule,120.37% of custom fee schedule,12,100,,,fee schedule,Pays 100% Medicare OPPS,15.6,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,12,100,,,fee schedule,Pays 100% Medicare OPPS,10.8,175.5,
C7 COMPLEMENT,3000625,CDM,302,RC,86160,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,12,100,,,fee schedule,Pays 100% Medicare OPPS,12,100,,,fee schedule,Pays 100% Medicare OPPS,12,100,,,fee schedule,Pays 100% Medicare OPPS,15.6,130,,,fee schedule,Pays 130% Medicare OPPS,18.18,120.37,,,fee schedule,120.37% of custom fee schedule,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.24,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,18.9,125.18,,,fee schedule,125.18% of custom fee schedule,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,12,100,,,fee schedule,Pays 100% Medicare OPPS,10.8,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,18.18,120.37,,,fee schedule,120.37% of custom fee schedule,12,100,,,fee schedule,Pays 100% Medicare OPPS,15.6,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,12,100,,,fee schedule,Pays 100% Medicare OPPS,10.8,175.5,
C8 COMPLEMENT,3000626,CDM,302,RC,86160,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,12,100,,,fee schedule,Pays 100% Medicare OPPS,12,100,,,fee schedule,Pays 100% Medicare OPPS,12,100,,,fee schedule,Pays 100% Medicare OPPS,15.6,130,,,fee schedule,Pays 130% Medicare OPPS,18.18,120.37,,,fee schedule,120.37% of custom fee schedule,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.24,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,18.9,125.18,,,fee schedule,125.18% of custom fee schedule,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,12,100,,,fee schedule,Pays 100% Medicare OPPS,10.8,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,18.18,120.37,,,fee schedule,120.37% of custom fee schedule,12,100,,,fee schedule,Pays 100% Medicare OPPS,15.6,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,12,100,,,fee schedule,Pays 100% Medicare OPPS,10.8,175.5,
C9 COMPLEMENT,3000627,CDM,302,RC,86160,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,12,100,,,fee schedule,Pays 100% Medicare OPPS,12,100,,,fee schedule,Pays 100% Medicare OPPS,12,100,,,fee schedule,Pays 100% Medicare OPPS,15.6,130,,,fee schedule,Pays 130% Medicare OPPS,18.18,120.37,,,fee schedule,120.37% of custom fee schedule,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.24,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,18.9,125.18,,,fee schedule,125.18% of custom fee schedule,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,12,100,,,fee schedule,Pays 100% Medicare OPPS,10.8,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,18.18,120.37,,,fee schedule,120.37% of custom fee schedule,12,100,,,fee schedule,Pays 100% Medicare OPPS,15.6,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,12,100,,,fee schedule,Pays 100% Medicare OPPS,10.8,175.5,
LITHIUM LEVEL,3080178,CDM,301,RC,80178,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,6.61,100,,,fee schedule,Pays 100% Medicare OPPS,6.61,100,,,fee schedule,Pays 100% Medicare OPPS,6.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.59,130,,,fee schedule,Pays 130% Medicare OPPS,10.01,120.37,,,fee schedule,120.37% of custom fee schedule,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.74,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,10.41,125.18,,,fee schedule,125.18% of custom fee schedule,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,6.61,100,,,fee schedule,Pays 100% Medicare OPPS,5.94,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,10.01,120.37,,,fee schedule,120.37% of custom fee schedule,6.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.59,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,6.61,100,,,fee schedule,Pays 100% Medicare OPPS,5.94,175.5,
CALCIUM IONIZED,3082330,CDM,301,RC,82330,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,13.68,100,,,fee schedule,Pays 100% Medicare OPPS,13.68,100,,,fee schedule,Pays 100% Medicare OPPS,13.68,100,,,fee schedule,Pays 100% Medicare OPPS,17.78,130,,,fee schedule,Pays 130% Medicare OPPS,20.68,120.37,,,fee schedule,120.37% of custom fee schedule,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.95,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,21.51,125.18,,,fee schedule,125.18% of custom fee schedule,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,13.68,100,,,fee schedule,Pays 100% Medicare OPPS,12.31,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,20.68,120.37,,,fee schedule,120.37% of custom fee schedule,13.68,100,,,fee schedule,Pays 100% Medicare OPPS,17.78,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,13.68,100,,,fee schedule,Pays 100% Medicare OPPS,12.31,175.5,
HEAVY METALS (BLOOD),3083018,CDM,301,RC,83018,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,21.96,100,,,fee schedule,Pays 100% Medicare OPPS,21.96,100,,,fee schedule,Pays 100% Medicare OPPS,21.96,100,,,fee schedule,Pays 100% Medicare OPPS,28.54,130,,,fee schedule,Pays 130% Medicare OPPS,33.23,120.37,,,fee schedule,120.37% of custom fee schedule,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.39,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,34.56,125.18,,,fee schedule,125.18% of custom fee schedule,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,21.96,100,,,fee schedule,Pays 100% Medicare OPPS,19.76,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,33.23,120.37,,,fee schedule,120.37% of custom fee schedule,21.96,100,,,fee schedule,Pays 100% Medicare OPPS,28.54,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,21.96,100,,,fee schedule,Pays 100% Medicare OPPS,19.76,175.5,
OSMOLALITY SERUM,3083930,CDM,301,RC,83930,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,6.61,100,,,fee schedule,Pays 100% Medicare OPPS,6.61,100,,,fee schedule,Pays 100% Medicare OPPS,6.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.59,130,,,fee schedule,Pays 130% Medicare OPPS,10.01,120.37,,,fee schedule,120.37% of custom fee schedule,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.74,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,10.41,125.18,,,fee schedule,125.18% of custom fee schedule,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,6.61,100,,,fee schedule,Pays 100% Medicare OPPS,5.94,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,10.01,120.37,,,fee schedule,120.37% of custom fee schedule,6.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.59,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,6.61,100,,,fee schedule,Pays 100% Medicare OPPS,5.94,175.5,
OSMOLALITY URINE,3083935,CDM,301,RC,83935,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,6.82,100,,,fee schedule,Pays 100% Medicare OPPS,6.82,100,,,fee schedule,Pays 100% Medicare OPPS,6.82,100,,,fee schedule,Pays 100% Medicare OPPS,8.86,130,,,fee schedule,Pays 130% Medicare OPPS,10.32,120.37,,,fee schedule,120.37% of custom fee schedule,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.95,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,10.73,125.18,,,fee schedule,125.18% of custom fee schedule,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,6.82,100,,,fee schedule,Pays 100% Medicare OPPS,6.13,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,10.32,120.37,,,fee schedule,120.37% of custom fee schedule,6.82,100,,,fee schedule,Pays 100% Medicare OPPS,8.86,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,6.82,100,,,fee schedule,Pays 100% Medicare OPPS,6.13,175.5,
OXALIC ACID URINE,3083945,CDM,301,RC,83945,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,14.45,100,,,fee schedule,Pays 100% Medicare OPPS,14.45,100,,,fee schedule,Pays 100% Medicare OPPS,14.45,100,,,fee schedule,Pays 100% Medicare OPPS,18.78,130,,,fee schedule,Pays 130% Medicare OPPS,19.49,120.37,,,fee schedule,120.37% of custom fee schedule,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.73,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,20.27,125.18,,,fee schedule,125.18% of custom fee schedule,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,14.45,100,,,fee schedule,Pays 100% Medicare OPPS,13,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,19.49,120.37,,,fee schedule,120.37% of custom fee schedule,14.45,100,,,fee schedule,Pays 100% Medicare OPPS,18.78,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,14.45,100,,,fee schedule,Pays 100% Medicare OPPS,13,175.5,
URIC ACID SERUM,3084550,CDM,301,RC,84550,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,4.51,100,,,fee schedule,Pays 100% Medicare OPPS,4.51,100,,,fee schedule,Pays 100% Medicare OPPS,4.51,100,,,fee schedule,Pays 100% Medicare OPPS,5.87,130,,,fee schedule,Pays 130% Medicare OPPS,6.84,120.37,,,fee schedule,120.37% of custom fee schedule,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.61,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,7.11,125.18,,,fee schedule,125.18% of custom fee schedule,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,4.51,100,,,fee schedule,Pays 100% Medicare OPPS,4.06,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,6.84,120.37,,,fee schedule,120.37% of custom fee schedule,4.51,100,,,fee schedule,Pays 100% Medicare OPPS,5.87,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,4.51,100,,,fee schedule,Pays 100% Medicare OPPS,4.06,175.5,
BLEEDING TIME,3085002,CDM,305,RC,85002,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,4.82,100,,,fee schedule,Pays 100% Medicare OPPS,4.82,100,,,fee schedule,Pays 100% Medicare OPPS,4.82,100,,,fee schedule,Pays 100% Medicare OPPS,6.26,130,,,fee schedule,Pays 130% Medicare OPPS,6.81,120.37,,,fee schedule,120.37% of custom fee schedule,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.91,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,7.09,125.18,,,fee schedule,125.18% of custom fee schedule,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,4.82,100,,,fee schedule,Pays 100% Medicare OPPS,4.33,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,6.81,120.37,,,fee schedule,120.37% of custom fee schedule,4.82,100,,,fee schedule,Pays 100% Medicare OPPS,6.26,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,4.82,100,,,fee schedule,Pays 100% Medicare OPPS,4.33,175.5,
CLOT TIME LEE WHITE,3085345,CDM,305,RC,85345,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,4.69,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,100,,,fee schedule,Pays 100% Medicare OPPS,4.69,100,,,fee schedule,Pays 100% Medicare OPPS,6.09,130,,,fee schedule,Pays 130% Medicare OPPS,5.24,120.37,,,fee schedule,120.37% of custom fee schedule,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.78,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,5.45,125.18,,,fee schedule,125.18% of custom fee schedule,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,4.69,100,,,fee schedule,Pays 100% Medicare OPPS,4.22,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,5.24,120.37,,,fee schedule,120.37% of custom fee schedule,4.69,100,,,fee schedule,Pays 100% Medicare OPPS,6.09,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,4.69,100,,,fee schedule,Pays 100% Medicare OPPS,4.22,175.5,
Coagulation assessment blood test,3085730,CDM,305,RC,85730,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,6.01,100,,,fee schedule,Pays 100% Medicare OPPS,6.01,100,,,fee schedule,Pays 100% Medicare OPPS,6.01,100,,,fee schedule,Pays 100% Medicare OPPS,7.81,130,,,fee schedule,Pays 130% Medicare OPPS,9.08,120.37,,,fee schedule,120.37% of custom fee schedule,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.13,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,9.44,125.18,,,fee schedule,125.18% of custom fee schedule,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,6.01,100,,,fee schedule,Pays 100% Medicare OPPS,5.4,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,9.08,120.37,,,fee schedule,120.37% of custom fee schedule,6.01,100,,,fee schedule,Pays 100% Medicare OPPS,7.81,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,6.01,100,,,fee schedule,Pays 100% Medicare OPPS,5.4,175.5,
COVID-19 RAPID IgM IgG,3086328,CDM,300,RC,86328,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,45.28,100,,,fee schedule,Pays 100% Medicare OPPS,45.28,100,,,fee schedule,Pays 100% Medicare OPPS,45.28,100,,,fee schedule,Pays 100% Medicare OPPS,58.86,130,,,fee schedule,Pays 130% Medicare OPPS,61.76,120.37,,,fee schedule,120.37% of custom fee schedule,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,46.18,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,64.23,125.18,,,fee schedule,125.18% of custom fee schedule,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,45.28,100,,,fee schedule,Pays 100% Medicare OPPS,40.75,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,61.76,120.37,,,fee schedule,120.37% of custom fee schedule,45.28,100,,,fee schedule,Pays 100% Medicare OPPS,58.86,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,45.28,100,,,fee schedule,Pays 100% Medicare OPPS,40.75,175.5,
BRUCELLA ABORTUS AB,3086622,CDM,302,RC,86622,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,8.93,100,,,fee schedule,Pays 100% Medicare OPPS,8.93,100,,,fee schedule,Pays 100% Medicare OPPS,8.93,100,,,fee schedule,Pays 100% Medicare OPPS,11.6,130,,,fee schedule,Pays 130% Medicare OPPS,13.52,120.37,,,fee schedule,120.37% of custom fee schedule,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.1,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,14.06,125.18,,,fee schedule,125.18% of custom fee schedule,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,8.93,100,,,fee schedule,Pays 100% Medicare OPPS,8.03,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,13.52,120.37,,,fee schedule,120.37% of custom fee schedule,8.93,100,,,fee schedule,Pays 100% Medicare OPPS,11.6,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,8.93,100,,,fee schedule,Pays 100% Medicare OPPS,8.03,175.5,
HERPES AB TYP I IgG,3086695,CDM,302,RC,86695,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,17.14,130,,,fee schedule,Pays 130% Medicare OPPS,19.97,120.37,,,fee schedule,120.37% of custom fee schedule,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.45,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,20.77,125.18,,,fee schedule,125.18% of custom fee schedule,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,11.87,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,19.97,120.37,,,fee schedule,120.37% of custom fee schedule,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,17.14,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,11.87,175.5,
HERPES AB TY II IgG,3086696,CDM,302,RC,86696,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,25.15,130,,,fee schedule,Pays 130% Medicare OPPS,29.31,120.37,,,fee schedule,120.37% of custom fee schedule,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.73,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,30.48,125.18,,,fee schedule,125.18% of custom fee schedule,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,17.41,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,29.31,120.37,,,fee schedule,120.37% of custom fee schedule,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,25.15,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,19.35,100,,,fee schedule,Pays 100% Medicare OPPS,17.41,175.5,
.RUBELLA,3086762,CDM,302,RC,,,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,48.75,100,,,fee schedule,Pays 100% Medicare OPPS,48.75,100,,,fee schedule,Pays 100% Medicare OPPS,48.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,175.5,90,,,percent of total billed charges,90% of total billed charges,68.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,175.5,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,165.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,39.72,175.5,
RC ANTIBODY ELUTION REF LAB,3086860,CDM,300,RC,86860,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,179.8,130,,,fee schedule,Pays 130% Medicare OPPS,7.37,120.37,,,fee schedule,120.37% of custom fee schedule,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,136.65,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,7.66,125.18,,,fee schedule,125.18% of custom fee schedule,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,120.57,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,7.37,120.37,,,fee schedule,120.37% of custom fee schedule,138.31,100,,,fee schedule,Pays 100% Medicare OPPS,179.8,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,7.37,179.8,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",4090766,CDM,760,RC,96366,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.65,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,68.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,37.26,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,175.5,
THUMB SPLINT VT51700,5007122,CDM,270,RC,,,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,48.75,100,,,fee schedule,Pays 100% Medicare OPPS,48.75,100,,,fee schedule,Pays 100% Medicare OPPS,48.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,175.5,90,,,percent of total billed charges,90% of total billed charges,68.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,175.5,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,165.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,39.72,175.5,
PT PROSTHETIC TRAINING(PER 15 MINS),5007761,CDM,420,RC,97761,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,39.5,100,,,fee schedule,Pays 100% Medicare OPPS,39.5,100,,,fee schedule,Pays 100% Medicare OPPS,39.5,100,,,fee schedule,Pays 100% Medicare OPPS,51.18,130,,,fee schedule,Pays 130% Medicare OPPS,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,40.29,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,68.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,39.5,100,,,fee schedule,Pays 100% Medicare OPPS,35.55,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,39.37,100,,,fee schedule,Pays 100% Medicare OPPS,51.18,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,39.5,100,,,fee schedule,Pays 100% Medicare OPPS,35.55,175.5,
PT ORTHOTIC TRAINING (PER SESSION),5097760,CDM,420,RC,97760,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,45.88,100,,,fee schedule,Pays 100% Medicare OPPS,45.88,100,,,fee schedule,Pays 100% Medicare OPPS,45.88,100,,,fee schedule,Pays 100% Medicare OPPS,58.96,130,,,fee schedule,Pays 130% Medicare OPPS,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,46.8,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,68.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,45.88,100,,,fee schedule,Pays 100% Medicare OPPS,41.29,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,45.35,100,,,fee schedule,Pays 100% Medicare OPPS,58.96,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,45.88,100,,,fee schedule,Pays 100% Medicare OPPS,39.72,175.5,
PT PROSTHETIC TRAINING(PER 15 MINS),5097761,CDM,420,RC,97761,HCPCS,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,39.5,100,,,fee schedule,Pays 100% Medicare OPPS,39.5,100,,,fee schedule,Pays 100% Medicare OPPS,39.5,100,,,fee schedule,Pays 100% Medicare OPPS,51.18,130,,,fee schedule,Pays 130% Medicare OPPS,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,40.29,102,,,fee schedule,Pays 102% Medicare OPPS,175.5,90,,,percent of total billed charges,90% of total billed charges,68.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,39.5,100,,,fee schedule,Pays 100% Medicare OPPS,35.55,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,39.37,100,,,fee schedule,Pays 100% Medicare OPPS,51.18,130,,,fee schedule,Pays 130% Medicare OPPS,165.75,85,,,percent of total billed charges,85% of total billed charges,39.5,100,,,fee schedule,Pays 100% Medicare OPPS,35.55,175.5,
BRACE DURA STEPPER LARGE,7905917,CDM,270,RC,,,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,48.75,100,,,fee schedule,Pays 100% Medicare OPPS,48.75,100,,,fee schedule,Pays 100% Medicare OPPS,48.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,175.5,90,,,percent of total billed charges,90% of total billed charges,68.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,175.5,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,165.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,39.72,175.5,
HIP KIT,7907160,CDM,270,RC,,,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,48.75,100,,,fee schedule,Pays 100% Medicare OPPS,48.75,100,,,fee schedule,Pays 100% Medicare OPPS,48.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,175.5,90,,,percent of total billed charges,90% of total billed charges,68.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,175.5,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,165.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,39.72,175.5,
LAP IRRIGATOR 0026870,7950085,CDM,270,RC,,,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,48.75,100,,,fee schedule,Pays 100% Medicare OPPS,48.75,100,,,fee schedule,Pays 100% Medicare OPPS,48.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,175.5,90,,,percent of total billed charges,90% of total billed charges,68.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,175.5,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,165.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,39.72,175.5,
SYRINGE GAUGE ASSEMBLY 5060-05,7950227,CDM,270,RC,,,Outpatient,,,195,156,,165.75,85,,,percent of total billed charges,85% of total billed charges,48.75,100,,,fee schedule,Pays 100% Medicare OPPS,48.75,100,,,fee schedule,Pays 100% Medicare OPPS,48.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,110.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,175.5,90,,,percent of total billed charges,90% of total billed charges,68.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,133.97,68.7,,,percent of total billed charges,68.7% of total billed charges,156,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,175.5,90,,,fee schedule,Pays 90% Medicare OPPS,113.1,58,,,percent of total billed charges,58% of total billed charges,39.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,165.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,39.72,175.5,
ACAPELLA VIBRATORY PEP THERAPY,7915718,CDM,270,RC,,,Outpatient,,,197,157.6,,167.45,85,,,percent of total billed charges,85% of total billed charges,49.25,100,,,fee schedule,Pays 100% Medicare OPPS,49.25,100,,,fee schedule,Pays 100% Medicare OPPS,49.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,40.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,111.31,56.5,,,percent of total billed charges,56.5 percent of total billed charges,111.31,56.5,,,percent of total billed charges,56.5 percent of total billed charges,111.31,56.5,,,percent of total billed charges,56.5 percent of total billed charges,111.31,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,177.3,90,,,percent of total billed charges,90% of total billed charges,68.95,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,135.34,68.7,,,percent of total billed charges,68.7% of total billed charges,157.6,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,177.3,90,,,fee schedule,Pays 90% Medicare OPPS,114.26,58,,,percent of total billed charges,58% of total billed charges,40.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,167.45,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,40.13,177.3,
CANNULA TWIST IN,1570854,CDM,272,RC,,,Outpatient,,,200,160,,170,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,40.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,180,90,,,percent of total billed charges,90% of total billed charges,70,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,137.4,68.7,,,percent of total billed charges,68.7% of total billed charges,160,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,180,90,,,fee schedule,Pays 90% Medicare OPPS,116,58,,,percent of total billed charges,58% of total billed charges,40.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,170,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,40.74,180,
CANNULA TWIST IN NOTCHED,1570855,CDM,272,RC,,,Outpatient,,,200,160,,170,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,40.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,180,90,,,percent of total billed charges,90% of total billed charges,70,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,137.4,68.7,,,percent of total billed charges,68.7% of total billed charges,160,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,180,90,,,fee schedule,Pays 90% Medicare OPPS,116,58,,,percent of total billed charges,58% of total billed charges,40.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,170,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,40.74,180,
CANNULA CONTOUR ERCP 5-4-3,1750029,CDM,272,RC,,,Outpatient,,,200,160,,170,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,40.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,180,90,,,percent of total billed charges,90% of total billed charges,70,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,137.4,68.7,,,percent of total billed charges,68.7% of total billed charges,160,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,180,90,,,fee schedule,Pays 90% Medicare OPPS,116,58,,,percent of total billed charges,58% of total billed charges,40.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,170,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,40.74,180,
NEOSYNEPH 2.5% (PHENYLEPHRINE)OPHT DROP,2600326,CDM,250,RC,,,Outpatient,,,200,160,,170,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,40.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,180,90,,,percent of total billed charges,90% of total billed charges,70,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,137.4,68.7,,,percent of total billed charges,68.7% of total billed charges,160,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,180,90,,,fee schedule,Pays 90% Medicare OPPS,116,58,,,percent of total billed charges,58% of total billed charges,40.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,170,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,40.74,180,
PT WORK HARDENING ADDON,5097546,CDM,420,RC,97546,HCPCS,Outpatient,,,200,160,,170,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,40.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,180,90,,,percent of total billed charges,90% of total billed charges,70,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,137.4,68.7,,,percent of total billed charges,68.7% of total billed charges,160,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,116,58,,,percent of total billed charges,58% of total billed charges,40.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,170,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,40.74,180,
**DO NOT USE**,7950030,CDM,272,RC,,,Outpatient,,,200,160,,170,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,40.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,180,90,,,percent of total billed charges,90% of total billed charges,70,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,137.4,68.7,,,percent of total billed charges,68.7% of total billed charges,160,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,116,58,,,percent of total billed charges,58% of total billed charges,40.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,170,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,40.74,180,
LINEAR CUTTER RELOAD TCR55,7950226,CDM,272,RC,,,Outpatient,,,200,160,,170,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,40.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,180,90,,,percent of total billed charges,90% of total billed charges,70,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,137.4,68.7,,,percent of total billed charges,68.7% of total billed charges,160,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,116,58,,,percent of total billed charges,58% of total billed charges,40.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,170,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,40.74,180,
ELECTRODE LAPAROSCOPIC 0018,7950296,CDM,272,RC,,,Outpatient,,,200,160,,170,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,40.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,113,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,180,90,,,percent of total billed charges,90% of total billed charges,70,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,137.4,68.7,,,percent of total billed charges,68.7% of total billed charges,160,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,116,58,,,percent of total billed charges,58% of total billed charges,40.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,170,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,40.74,180,
AZACTAM (AZTREONAM) 1GM VIAL,2600082,CDM,636,RC,,,Both,,,210,168,,178.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,189,90,,,percent of total billed charges,90% of total billed charges,73.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,144.27,68.7,,,percent of total billed charges,68.7% of total billed charges,168,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,121.8,58,,,percent of total billed charges,58% of total billed charges,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,178.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,42.78,189,
PROTONIX (PANTOPRAZOLE) INJ 40MG,2605174,CDM,250,RC,S0164,HCPCS,Outpatient,,,210,168,,178.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,189,90,,,percent of total billed charges,90% of total billed charges,73.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,144.27,68.7,,,percent of total billed charges,68.7% of total billed charges,168,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,121.8,58,,,percent of total billed charges,58% of total billed charges,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,178.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,42.78,189,
MOLECULAR DGN ENZ,3000202,CDM,301,RC,83892,HCPCS,Outpatient,,,210,168,,178.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,189,90,,,percent of total billed charges,90% of total billed charges,73.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,144.27,68.7,,,percent of total billed charges,68.7% of total billed charges,168,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,121.8,58,,,percent of total billed charges,58% of total billed charges,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,178.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,42.78,189,
"MOLECULAR DIAG, AMP PNA,1",3000208,CDM,301,RC,81223,HCPCS,Outpatient,,,210,168,,178.5,85,,,percent of total billed charges,85% of total billed charges,499,100,,,fee schedule,Pays 100% Medicare OPPS,499,100,,,fee schedule,Pays 100% Medicare OPPS,499,100,,,fee schedule,Pays 100% Medicare OPPS,648.7,130,,,fee schedule,Pays 130% Medicare OPPS,1155.55,120.37,,,fee schedule,120.37% of custom fee schedule,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,508.98,102,,,fee schedule,Pays 102% Medicare OPPS,189,90,,,percent of total billed charges,90% of total billed charges,1201.73,125.18,,,fee schedule,125.18% of custom fee schedule,144.27,68.7,,,percent of total billed charges,68.7% of total billed charges,168,80,,,percent of total billed charges,80 percent of total billed charges,499,100,,,fee schedule,Pays 100% Medicare OPPS,449.1,90,,,fee schedule,Pays 90% Medicare OPPS,121.8,58,,,percent of total billed charges,58% of total billed charges,1155.55,120.37,,,fee schedule,120.37% of custom fee schedule,499,100,,,fee schedule,Pays 100% Medicare OPPS,648.7,130,,,fee schedule,Pays 130% Medicare OPPS,178.5,85,,,percent of total billed charges,85% of total billed charges,499,100,,,fee schedule,Pays 100% Medicare OPPS,118.65,1201.73,
"MOLECULAR DIAG, INTERPRET",3000209,CDM,301,RC,83912,HCPCS,Outpatient,,,210,168,,178.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,189,90,,,percent of total billed charges,90% of total billed charges,73.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,144.27,68.7,,,percent of total billed charges,68.7% of total billed charges,168,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,121.8,58,,,percent of total billed charges,58% of total billed charges,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,178.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,42.78,189,
PSA (prostate specific antigen),3000346,CDM,301,RC,84153,HCPCS,Outpatient,,,210,168,,178.5,85,,,percent of total billed charges,85% of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,23.9,130,,,fee schedule,Pays 130% Medicare OPPS,27.84,120.37,,,fee schedule,120.37% of custom fee schedule,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.75,102,,,fee schedule,Pays 102% Medicare OPPS,189,90,,,percent of total billed charges,90% of total billed charges,28.95,125.18,,,fee schedule,125.18% of custom fee schedule,144.27,68.7,,,percent of total billed charges,68.7% of total billed charges,168,80,,,percent of total billed charges,80 percent of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.55,90,,,fee schedule,Pays 90% Medicare OPPS,121.8,58,,,percent of total billed charges,58% of total billed charges,27.84,120.37,,,fee schedule,120.37% of custom fee schedule,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,23.9,130,,,fee schedule,Pays 130% Medicare OPPS,178.5,85,,,percent of total billed charges,85% of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.55,189,
3RD LDH BODY FLUID,3000545,CDM,301,RC,83615,HCPCS,Outpatient,,,210,168,,178.5,85,,,percent of total billed charges,85% of total billed charges,6.04,100,,,fee schedule,Pays 100% Medicare OPPS,6.04,100,,,fee schedule,Pays 100% Medicare OPPS,6.04,100,,,fee schedule,Pays 100% Medicare OPPS,7.85,130,,,fee schedule,Pays 130% Medicare OPPS,7.64,120.37,,,fee schedule,120.37% of custom fee schedule,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.16,102,,,fee schedule,Pays 102% Medicare OPPS,189,90,,,percent of total billed charges,90% of total billed charges,7.95,125.18,,,fee schedule,125.18% of custom fee schedule,144.27,68.7,,,percent of total billed charges,68.7% of total billed charges,168,80,,,percent of total billed charges,80 percent of total billed charges,6.04,100,,,fee schedule,Pays 100% Medicare OPPS,5.43,90,,,fee schedule,Pays 90% Medicare OPPS,121.8,58,,,percent of total billed charges,58% of total billed charges,7.64,120.37,,,fee schedule,120.37% of custom fee schedule,6.04,100,,,fee schedule,Pays 100% Medicare OPPS,7.85,130,,,fee schedule,Pays 130% Medicare OPPS,178.5,85,,,percent of total billed charges,85% of total billed charges,6.04,100,,,fee schedule,Pays 100% Medicare OPPS,5.43,189,
DRUG SCREEN/W ETOH,3000605,CDM,301,RC,80377,HCPCS,Outpatient,,,210,168,,178.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,189,90,,,percent of total billed charges,90% of total billed charges,73.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,144.27,68.7,,,percent of total billed charges,68.7% of total billed charges,168,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,121.8,58,,,percent of total billed charges,58% of total billed charges,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,178.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,42.78,189,
.TRANSFERRIN CARBOHYDRATE,3082373,CDM,301,RC,82373,HCPCS,Outpatient,,,210,168,,178.5,85,,,percent of total billed charges,85% of total billed charges,18.05,100,,,fee schedule,Pays 100% Medicare OPPS,18.05,100,,,fee schedule,Pays 100% Medicare OPPS,18.05,100,,,fee schedule,Pays 100% Medicare OPPS,23.47,130,,,fee schedule,Pays 130% Medicare OPPS,9.09,120.37,,,fee schedule,120.37% of custom fee schedule,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.42,102,,,fee schedule,Pays 102% Medicare OPPS,189,90,,,percent of total billed charges,90% of total billed charges,9.45,125.18,,,fee schedule,125.18% of custom fee schedule,144.27,68.7,,,percent of total billed charges,68.7% of total billed charges,168,80,,,percent of total billed charges,80 percent of total billed charges,18.05,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,90,,,fee schedule,Pays 90% Medicare OPPS,121.8,58,,,percent of total billed charges,58% of total billed charges,9.09,120.37,,,fee schedule,120.37% of custom fee schedule,18.05,100,,,fee schedule,Pays 100% Medicare OPPS,23.47,130,,,fee schedule,Pays 130% Medicare OPPS,178.5,85,,,percent of total billed charges,85% of total billed charges,18.05,100,,,fee schedule,Pays 100% Medicare OPPS,9.09,189,
CPK,3082550,CDM,301,RC,82550,HCPCS,Outpatient,,,210,168,,178.5,85,,,percent of total billed charges,85% of total billed charges,6.51,100,,,fee schedule,Pays 100% Medicare OPPS,6.51,100,,,fee schedule,Pays 100% Medicare OPPS,6.51,100,,,fee schedule,Pays 100% Medicare OPPS,8.46,130,,,fee schedule,Pays 130% Medicare OPPS,7.64,120.37,,,fee schedule,120.37% of custom fee schedule,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.64,102,,,fee schedule,Pays 102% Medicare OPPS,189,90,,,percent of total billed charges,90% of total billed charges,7.95,125.18,,,fee schedule,125.18% of custom fee schedule,144.27,68.7,,,percent of total billed charges,68.7% of total billed charges,168,80,,,percent of total billed charges,80 percent of total billed charges,6.51,100,,,fee schedule,Pays 100% Medicare OPPS,5.85,90,,,fee schedule,Pays 90% Medicare OPPS,121.8,58,,,percent of total billed charges,58% of total billed charges,7.64,120.37,,,fee schedule,120.37% of custom fee schedule,6.51,100,,,fee schedule,Pays 100% Medicare OPPS,8.46,130,,,fee schedule,Pays 130% Medicare OPPS,178.5,85,,,percent of total billed charges,85% of total billed charges,6.51,100,,,fee schedule,Pays 100% Medicare OPPS,5.85,189,
LDH,3083615,CDM,301,RC,83615,HCPCS,Outpatient,,,210,168,,178.5,85,,,percent of total billed charges,85% of total billed charges,6.04,100,,,fee schedule,Pays 100% Medicare OPPS,6.04,100,,,fee schedule,Pays 100% Medicare OPPS,6.04,100,,,fee schedule,Pays 100% Medicare OPPS,7.85,130,,,fee schedule,Pays 130% Medicare OPPS,7.64,120.37,,,fee schedule,120.37% of custom fee schedule,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.16,102,,,fee schedule,Pays 102% Medicare OPPS,189,90,,,percent of total billed charges,90% of total billed charges,7.95,125.18,,,fee schedule,125.18% of custom fee schedule,144.27,68.7,,,percent of total billed charges,68.7% of total billed charges,168,80,,,percent of total billed charges,80 percent of total billed charges,6.04,100,,,fee schedule,Pays 100% Medicare OPPS,5.43,90,,,fee schedule,Pays 90% Medicare OPPS,121.8,58,,,percent of total billed charges,58% of total billed charges,7.64,120.37,,,fee schedule,120.37% of custom fee schedule,6.04,100,,,fee schedule,Pays 100% Medicare OPPS,7.85,130,,,fee schedule,Pays 130% Medicare OPPS,178.5,85,,,percent of total billed charges,85% of total billed charges,6.04,100,,,fee schedule,Pays 100% Medicare OPPS,5.43,189,
MOLECULAR DIAG,3083890,CDM,301,RC,83890,HCPCS,Outpatient,,,210,168,,178.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,189,90,,,percent of total billed charges,90% of total billed charges,73.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,144.27,68.7,,,percent of total billed charges,68.7% of total billed charges,168,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,121.8,58,,,percent of total billed charges,58% of total billed charges,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,178.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,42.78,189,
MOLECULAR DGN SEP,3083894,CDM,300,RC,83894,HCPCS,Outpatient,,,210,168,,178.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,189,90,,,percent of total billed charges,90% of total billed charges,73.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,144.27,68.7,,,percent of total billed charges,68.7% of total billed charges,168,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,121.8,58,,,percent of total billed charges,58% of total billed charges,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,178.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,42.78,189,
PSA (prostate specific antigen) measurement,3084154,CDM,301,RC,84154,HCPCS,Outpatient,,,210,168,,178.5,85,,,percent of total billed charges,85% of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,23.9,130,,,fee schedule,Pays 130% Medicare OPPS,27.84,120.37,,,fee schedule,120.37% of custom fee schedule,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.75,102,,,fee schedule,Pays 102% Medicare OPPS,189,90,,,percent of total billed charges,90% of total billed charges,28.95,125.18,,,fee schedule,125.18% of custom fee schedule,144.27,68.7,,,percent of total billed charges,68.7% of total billed charges,168,80,,,percent of total billed charges,80 percent of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.55,90,,,fee schedule,Pays 90% Medicare OPPS,121.8,58,,,percent of total billed charges,58% of total billed charges,27.84,120.37,,,fee schedule,120.37% of custom fee schedule,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,23.9,130,,,fee schedule,Pays 130% Medicare OPPS,178.5,85,,,percent of total billed charges,85% of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.55,189,
TRANSFERRIN LEVEL,3084466,CDM,301,RC,84466,HCPCS,Outpatient,,,210,168,,178.5,85,,,percent of total billed charges,85% of total billed charges,12.76,100,,,fee schedule,Pays 100% Medicare OPPS,12.76,100,,,fee schedule,Pays 100% Medicare OPPS,12.76,100,,,fee schedule,Pays 100% Medicare OPPS,16.58,130,,,fee schedule,Pays 130% Medicare OPPS,19.33,120.37,,,fee schedule,120.37% of custom fee schedule,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.01,102,,,fee schedule,Pays 102% Medicare OPPS,189,90,,,percent of total billed charges,90% of total billed charges,20.1,125.18,,,fee schedule,125.18% of custom fee schedule,144.27,68.7,,,percent of total billed charges,68.7% of total billed charges,168,80,,,percent of total billed charges,80 percent of total billed charges,12.76,100,,,fee schedule,Pays 100% Medicare OPPS,11.48,90,,,fee schedule,Pays 90% Medicare OPPS,121.8,58,,,percent of total billed charges,58% of total billed charges,19.33,120.37,,,fee schedule,120.37% of custom fee schedule,12.76,100,,,fee schedule,Pays 100% Medicare OPPS,16.58,130,,,fee schedule,Pays 130% Medicare OPPS,178.5,85,,,percent of total billed charges,85% of total billed charges,12.76,100,,,fee schedule,Pays 100% Medicare OPPS,11.48,189,
SICKLE CELL PREP,3085660,CDM,305,RC,85660,HCPCS,Outpatient,,,210,168,,178.5,85,,,percent of total billed charges,85% of total billed charges,5.51,100,,,fee schedule,Pays 100% Medicare OPPS,5.51,100,,,fee schedule,Pays 100% Medicare OPPS,5.51,100,,,fee schedule,Pays 100% Medicare OPPS,7.16,130,,,fee schedule,Pays 130% Medicare OPPS,8.35,120.37,,,fee schedule,120.37% of custom fee schedule,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.62,102,,,fee schedule,Pays 102% Medicare OPPS,189,90,,,percent of total billed charges,90% of total billed charges,8.69,125.18,,,fee schedule,125.18% of custom fee schedule,144.27,68.7,,,percent of total billed charges,68.7% of total billed charges,168,80,,,percent of total billed charges,80 percent of total billed charges,5.51,100,,,fee schedule,Pays 100% Medicare OPPS,4.95,90,,,fee schedule,Pays 90% Medicare OPPS,121.8,58,,,percent of total billed charges,58% of total billed charges,8.35,120.37,,,fee schedule,120.37% of custom fee schedule,5.51,100,,,fee schedule,Pays 100% Medicare OPPS,7.16,130,,,fee schedule,Pays 130% Medicare OPPS,178.5,85,,,percent of total billed charges,85% of total billed charges,5.51,100,,,fee schedule,Pays 100% Medicare OPPS,4.95,189,
ASPERGILLUS ANTIBODY SCREEN,3086606,CDM,302,RC,86606,HCPCS,Outpatient,,,210,168,,178.5,85,,,percent of total billed charges,85% of total billed charges,15.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.05,100,,,fee schedule,Pays 100% Medicare OPPS,19.56,130,,,fee schedule,Pays 130% Medicare OPPS,22.79,120.37,,,fee schedule,120.37% of custom fee schedule,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.35,102,,,fee schedule,Pays 102% Medicare OPPS,189,90,,,percent of total billed charges,90% of total billed charges,23.7,125.18,,,fee schedule,125.18% of custom fee schedule,144.27,68.7,,,percent of total billed charges,68.7% of total billed charges,168,80,,,percent of total billed charges,80 percent of total billed charges,15.05,100,,,fee schedule,Pays 100% Medicare OPPS,13.54,90,,,fee schedule,Pays 90% Medicare OPPS,121.8,58,,,percent of total billed charges,58% of total billed charges,22.79,120.37,,,fee schedule,120.37% of custom fee schedule,15.05,100,,,fee schedule,Pays 100% Medicare OPPS,19.56,130,,,fee schedule,Pays 130% Medicare OPPS,178.5,85,,,percent of total billed charges,85% of total billed charges,15.05,100,,,fee schedule,Pays 100% Medicare OPPS,13.54,189,
BLASTOMYCES ANTIBODIES,3086612,CDM,302,RC,86612,HCPCS,Outpatient,,,210,168,,178.5,85,,,percent of total billed charges,85% of total billed charges,12.9,100,,,fee schedule,Pays 100% Medicare OPPS,12.9,100,,,fee schedule,Pays 100% Medicare OPPS,12.9,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,130,,,fee schedule,Pays 130% Medicare OPPS,19.54,120.37,,,fee schedule,120.37% of custom fee schedule,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.15,102,,,fee schedule,Pays 102% Medicare OPPS,189,90,,,percent of total billed charges,90% of total billed charges,20.32,125.18,,,fee schedule,125.18% of custom fee schedule,144.27,68.7,,,percent of total billed charges,68.7% of total billed charges,168,80,,,percent of total billed charges,80 percent of total billed charges,12.9,100,,,fee schedule,Pays 100% Medicare OPPS,11.61,90,,,fee schedule,Pays 90% Medicare OPPS,121.8,58,,,percent of total billed charges,58% of total billed charges,19.54,120.37,,,fee schedule,120.37% of custom fee schedule,12.9,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,130,,,fee schedule,Pays 130% Medicare OPPS,178.5,85,,,percent of total billed charges,85% of total billed charges,12.9,100,,,fee schedule,Pays 100% Medicare OPPS,11.61,189,
COCCIDIOIDES ANTIBODIES,3086635,CDM,302,RC,86635,HCPCS,Outpatient,,,210,168,,178.5,85,,,percent of total billed charges,85% of total billed charges,11.47,100,,,fee schedule,Pays 100% Medicare OPPS,11.47,100,,,fee schedule,Pays 100% Medicare OPPS,11.47,100,,,fee schedule,Pays 100% Medicare OPPS,14.91,130,,,fee schedule,Pays 130% Medicare OPPS,17.37,120.37,,,fee schedule,120.37% of custom fee schedule,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.69,102,,,fee schedule,Pays 102% Medicare OPPS,189,90,,,percent of total billed charges,90% of total billed charges,18.06,125.18,,,fee schedule,125.18% of custom fee schedule,144.27,68.7,,,percent of total billed charges,68.7% of total billed charges,168,80,,,percent of total billed charges,80 percent of total billed charges,11.47,100,,,fee schedule,Pays 100% Medicare OPPS,10.32,90,,,fee schedule,Pays 90% Medicare OPPS,121.8,58,,,percent of total billed charges,58% of total billed charges,17.37,120.37,,,fee schedule,120.37% of custom fee schedule,11.47,100,,,fee schedule,Pays 100% Medicare OPPS,14.91,130,,,fee schedule,Pays 130% Medicare OPPS,178.5,85,,,percent of total billed charges,85% of total billed charges,11.47,100,,,fee schedule,Pays 100% Medicare OPPS,10.32,189,
HISTOPLASMA ANTIBODIES,3086698,CDM,302,RC,86698,HCPCS,Outpatient,,,210,168,,178.5,85,,,percent of total billed charges,85% of total billed charges,13.79,100,,,fee schedule,Pays 100% Medicare OPPS,13.79,100,,,fee schedule,Pays 100% Medicare OPPS,13.79,100,,,fee schedule,Pays 100% Medicare OPPS,17.92,130,,,fee schedule,Pays 130% Medicare OPPS,18.91,120.37,,,fee schedule,120.37% of custom fee schedule,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.06,102,,,fee schedule,Pays 102% Medicare OPPS,189,90,,,percent of total billed charges,90% of total billed charges,19.67,125.18,,,fee schedule,125.18% of custom fee schedule,144.27,68.7,,,percent of total billed charges,68.7% of total billed charges,168,80,,,percent of total billed charges,80 percent of total billed charges,13.79,100,,,fee schedule,Pays 100% Medicare OPPS,12.41,90,,,fee schedule,Pays 90% Medicare OPPS,121.8,58,,,percent of total billed charges,58% of total billed charges,18.91,120.37,,,fee schedule,120.37% of custom fee schedule,13.79,100,,,fee schedule,Pays 100% Medicare OPPS,17.92,130,,,fee schedule,Pays 130% Medicare OPPS,178.5,85,,,percent of total billed charges,85% of total billed charges,13.79,100,,,fee schedule,Pays 100% Medicare OPPS,12.41,189,
NM TC99M HEPATOLITE,4500034,CDM,343,RC,A9510,HCPCS,Outpatient,,,210,168,,178.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,189,90,,,percent of total billed charges,90% of total billed charges,73.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,144.27,68.7,,,percent of total billed charges,68.7% of total billed charges,168,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,121.8,58,,,percent of total billed charges,58% of total billed charges,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,178.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,42.78,189,
ATTENDANCE AT DELIVERY,5599436,CDM,460,RC,99464,HCPCS,Outpatient,,,210,168,,178.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,189,90,,,percent of total billed charges,90% of total billed charges,73.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,144.27,68.7,,,percent of total billed charges,68.7% of total billed charges,168,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,121.8,58,,,percent of total billed charges,58% of total billed charges,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,178.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,42.78,189,
MYRINGOTOMY TUBE,7901018,CDM,270,RC,,,Outpatient,,,210,168,,178.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,189,90,,,percent of total billed charges,90% of total billed charges,73.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,144.27,68.7,,,percent of total billed charges,68.7% of total billed charges,168,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,121.8,58,,,percent of total billed charges,58% of total billed charges,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,178.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,42.78,189,
**DO NOT USE**,7905094,CDM,272,RC,,,Outpatient,,,210,168,,178.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,189,90,,,percent of total billed charges,90% of total billed charges,73.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,144.27,68.7,,,percent of total billed charges,68.7% of total billed charges,168,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,121.8,58,,,percent of total billed charges,58% of total billed charges,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,178.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,42.78,189,
TRACHEOSTOMY TUBE SZ 4 CFS,7905578,CDM,272,RC,,,Outpatient,,,210,168,,178.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,189,90,,,percent of total billed charges,90% of total billed charges,73.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,144.27,68.7,,,percent of total billed charges,68.7% of total billed charges,168,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,121.8,58,,,percent of total billed charges,58% of total billed charges,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,178.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,42.78,189,
BRACE WRIST C5547620X,7907170,CDM,270,RC,,,Outpatient,,,210,168,,178.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,189,90,,,percent of total billed charges,90% of total billed charges,73.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,144.27,68.7,,,percent of total billed charges,68.7% of total billed charges,168,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,121.8,58,,,percent of total billed charges,58% of total billed charges,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,178.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,42.78,189,
CATH CHOLANGIOGRAM 20018-M55,7950245,CDM,270,RC,,,Outpatient,,,210,168,,178.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,189,90,,,percent of total billed charges,90% of total billed charges,73.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,144.27,68.7,,,percent of total billed charges,68.7% of total billed charges,168,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,121.8,58,,,percent of total billed charges,58% of total billed charges,42.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,178.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,42.78,189,
INTRO OF NEEDLE OR ENTRACATHETER,1036000,CDM,762,RC,36000,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,193.5,90,,,percent of total billed charges,90% of total billed charges,75.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,124.7,58,,,percent of total billed charges,58% of total billed charges,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,182.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,43.8,193.5,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",1090776,CDM,760,RC,96376,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,193.5,90,,,percent of total billed charges,90% of total billed charges,75.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,124.7,58,,,percent of total billed charges,58% of total billed charges,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,182.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,43.8,193.5,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",1590776,CDM,760,RC,96376,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,193.5,90,,,percent of total billed charges,90% of total billed charges,75.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,124.7,58,,,percent of total billed charges,58% of total billed charges,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,182.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,43.8,193.5,
INTRO OF NEEDLE OR ENTRACATHETER,2036000,CDM,450,RC,36000,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,193.5,90,,,percent of total billed charges,90% of total billed charges,75.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,124.7,58,,,percent of total billed charges,58% of total billed charges,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,182.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,43.8,193.5,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",2090776,CDM,450,RC,96376,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,193.5,90,,,percent of total billed charges,90% of total billed charges,75.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,124.7,58,,,percent of total billed charges,58% of total billed charges,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,182.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,43.8,193.5,
IRRIGATION OF IMPLANTED VENOUS ACCESS,2096523,CDM,450,RC,96523,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,65.72,130,,,fee schedule,Pays 130% Medicare OPPS,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,51,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,75.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,45,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,50.55,100,,,fee schedule,Pays 100% Medicare OPPS,65.72,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,43.8,193.5,
EPOGEN 1000 UNITS (> 10000 UNITS),2600021,CDM,636,RC,J0885,HCPCS,Both,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,8.36,100,,,fee schedule,Pays 100% Medicare OPPS,8.36,100,,,fee schedule,Pays 100% Medicare OPPS,8.36,100,,,fee schedule,Pays 100% Medicare OPPS,9.21,130,,,fee schedule,Pays 130% Medicare OPPS,10.07,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.52,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,10.48,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,8.36,100,,,fee schedule,Pays 100% Medicare OPPS,7.53,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,10.07,120.37,,,fee schedule,120.37% of custom fee schedule,7.09,100,,,fee schedule,Pays 100% Medicare OPPS,9.21,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,8.36,100,,,fee schedule,Pays 100% Medicare OPPS,7.09,193.5,
TERAZOL-3 (TERCONAZOLE) VAG CRM,2600259,CDM,637,RC,,,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,193.5,90,,,percent of total billed charges,90% of total billed charges,75.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,124.7,58,,,percent of total billed charges,58% of total billed charges,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,182.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,43.8,193.5,
CIPRO (CIPROFLOXACIN) 400MG IV PREMIX,2601023,CDM,250,RC,J0744,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,193.5,90,,,percent of total billed charges,90% of total billed charges,75.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,124.7,58,,,percent of total billed charges,58% of total billed charges,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,182.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,43.8,193.5,
"DRUG SCREEN, UA (MEDICAL)",3000093,CDM,301,RC,G0481,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,156.59,100,,,fee schedule,Pays 100% Medicare OPPS,156.59,100,,,fee schedule,Pays 100% Medicare OPPS,156.59,100,,,fee schedule,Pays 100% Medicare OPPS,203.56,130,,,fee schedule,Pays 130% Medicare OPPS,155.02,120.37,,,fee schedule,120.37% of custom fee schedule,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,159.72,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,161.22,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,156.59,100,,,fee schedule,Pays 100% Medicare OPPS,140.93,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,155.02,120.37,,,fee schedule,120.37% of custom fee schedule,156.59,100,,,fee schedule,Pays 100% Medicare OPPS,203.56,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,156.59,100,,,fee schedule,Pays 100% Medicare OPPS,121.48,203.56,
.IMMUNOFIX ELEC (SPEP W IM,3000166,CDM,302,RC,86334,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,22.34,100,,,fee schedule,Pays 100% Medicare OPPS,22.34,100,,,fee schedule,Pays 100% Medicare OPPS,22.34,100,,,fee schedule,Pays 100% Medicare OPPS,29.04,130,,,fee schedule,Pays 130% Medicare OPPS,33.81,120.37,,,fee schedule,120.37% of custom fee schedule,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.78,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,35.16,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,22.34,100,,,fee schedule,Pays 100% Medicare OPPS,20.1,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,33.81,120.37,,,fee schedule,120.37% of custom fee schedule,22.34,100,,,fee schedule,Pays 100% Medicare OPPS,29.04,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,22.34,100,,,fee schedule,Pays 100% Medicare OPPS,20.1,193.5,
.TRIPLE TEST (MAFP),3000315,CDM,301,RC,82105,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,16.77,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,100,,,fee schedule,Pays 100% Medicare OPPS,21.8,130,,,fee schedule,Pays 130% Medicare OPPS,25.4,120.37,,,fee schedule,120.37% of custom fee schedule,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.1,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,26.41,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,16.77,100,,,fee schedule,Pays 100% Medicare OPPS,15.09,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,25.4,120.37,,,fee schedule,120.37% of custom fee schedule,16.77,100,,,fee schedule,Pays 100% Medicare OPPS,21.8,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,16.77,100,,,fee schedule,Pays 100% Medicare OPPS,15.09,193.5,
TZANCK PREP,3000320,CDM,306,RC,87207,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,5.99,100,,,fee schedule,Pays 100% Medicare OPPS,5.99,100,,,fee schedule,Pays 100% Medicare OPPS,5.99,100,,,fee schedule,Pays 100% Medicare OPPS,7.78,130,,,fee schedule,Pays 130% Medicare OPPS,9.06,120.37,,,fee schedule,120.37% of custom fee schedule,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.1,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,9.43,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,5.99,100,,,fee schedule,Pays 100% Medicare OPPS,5.39,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,9.06,120.37,,,fee schedule,120.37% of custom fee schedule,5.99,100,,,fee schedule,Pays 100% Medicare OPPS,7.78,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,5.99,100,,,fee schedule,Pays 100% Medicare OPPS,5.39,193.5,
Blood test to evaluate thyroid function,3000544,CDM,301,RC,84439,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,9.02,100,,,fee schedule,Pays 100% Medicare OPPS,9.02,100,,,fee schedule,Pays 100% Medicare OPPS,9.02,100,,,fee schedule,Pays 100% Medicare OPPS,11.72,130,,,fee schedule,Pays 130% Medicare OPPS,13.65,120.37,,,fee schedule,120.37% of custom fee schedule,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.2,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,14.2,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,9.02,100,,,fee schedule,Pays 100% Medicare OPPS,8.11,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,13.65,120.37,,,fee schedule,120.37% of custom fee schedule,9.02,100,,,fee schedule,Pays 100% Medicare OPPS,11.72,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,9.02,100,,,fee schedule,Pays 100% Medicare OPPS,8.11,193.5,
RBC ANTIBODY TYPING,3000592,CDM,300,RC,86905,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,370.6,130,,,fee schedule,Pays 130% Medicare OPPS,5.79,120.37,,,fee schedule,120.37% of custom fee schedule,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,266.86,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,6.02,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,235.46,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,5.79,120.37,,,fee schedule,120.37% of custom fee schedule,285.08,100,,,fee schedule,Pays 100% Medicare OPPS,370.6,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,5.79,370.6,
"ANTIBODY ID,TITER, AND TYPING",3000593,CDM,302,RC,86900,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,4.51,120.37,,,fee schedule,120.37% of custom fee schedule,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,4.69,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,4.51,120.37,,,fee schedule,120.37% of custom fee schedule,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,4.51,193.5,
MULLERIAN HORMONE ANTIBODY,3000696,CDM,302,RC,82397,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,14.12,100,,,fee schedule,Pays 100% Medicare OPPS,14.12,100,,,fee schedule,Pays 100% Medicare OPPS,14.12,100,,,fee schedule,Pays 100% Medicare OPPS,18.35,130,,,fee schedule,Pays 130% Medicare OPPS,21.39,120.37,,,fee schedule,120.37% of custom fee schedule,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.4,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,22.24,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,14.12,100,,,fee schedule,Pays 100% Medicare OPPS,12.7,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,21.39,120.37,,,fee schedule,120.37% of custom fee schedule,14.12,100,,,fee schedule,Pays 100% Medicare OPPS,18.35,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,14.12,100,,,fee schedule,Pays 100% Medicare OPPS,12.7,193.5,
Testing for presence of drug,3000800,CDM,301,RC,80307,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,80.78,130,,,fee schedule,Pays 130% Medicare OPPS,73.62,120.37,,,fee schedule,120.37% of custom fee schedule,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,63.38,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,76.56,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,55.92,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,73.62,120.37,,,fee schedule,120.37% of custom fee schedule,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,80.78,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,55.92,193.5,
.THYROGLOBULIN AB,3007032,CDM,302,RC,86800,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,15.91,100,,,fee schedule,Pays 100% Medicare OPPS,15.91,100,,,fee schedule,Pays 100% Medicare OPPS,15.91,100,,,fee schedule,Pays 100% Medicare OPPS,20.68,130,,,fee schedule,Pays 130% Medicare OPPS,24.07,120.37,,,fee schedule,120.37% of custom fee schedule,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.22,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,25.04,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,15.91,100,,,fee schedule,Pays 100% Medicare OPPS,14.31,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,24.07,120.37,,,fee schedule,120.37% of custom fee schedule,15.91,100,,,fee schedule,Pays 100% Medicare OPPS,20.68,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,15.91,100,,,fee schedule,Pays 100% Medicare OPPS,14.31,193.5,
.THYROGLOBULIN PANEL,3007033,CDM,302,RC,84432,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,16.05,100,,,fee schedule,Pays 100% Medicare OPPS,16.05,100,,,fee schedule,Pays 100% Medicare OPPS,16.05,100,,,fee schedule,Pays 100% Medicare OPPS,20.87,130,,,fee schedule,Pays 130% Medicare OPPS,24.31,120.37,,,fee schedule,120.37% of custom fee schedule,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.38,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,25.29,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,16.05,100,,,fee schedule,Pays 100% Medicare OPPS,14.45,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,24.31,120.37,,,fee schedule,120.37% of custom fee schedule,16.05,100,,,fee schedule,Pays 100% Medicare OPPS,20.87,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,16.05,100,,,fee schedule,Pays 100% Medicare OPPS,14.45,193.5,
THYROGLOBULIN QUANT AB,3007034,CDM,302,RC,,,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,193.5,90,,,percent of total billed charges,90% of total billed charges,75.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,124.7,58,,,percent of total billed charges,58% of total billed charges,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,182.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,43.8,193.5,
VITAMIN C LEVEL,3082180,CDM,301,RC,82180,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,9.89,100,,,fee schedule,Pays 100% Medicare OPPS,9.89,100,,,fee schedule,Pays 100% Medicare OPPS,9.89,100,,,fee schedule,Pays 100% Medicare OPPS,12.85,130,,,fee schedule,Pays 130% Medicare OPPS,13.37,120.37,,,fee schedule,120.37% of custom fee schedule,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,10.08,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,13.91,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,9.89,100,,,fee schedule,Pays 100% Medicare OPPS,8.9,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,13.37,120.37,,,fee schedule,120.37% of custom fee schedule,9.89,100,,,fee schedule,Pays 100% Medicare OPPS,12.85,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,9.89,100,,,fee schedule,Pays 100% Medicare OPPS,8.9,193.5,
.CREA CLR (24HR UA CC),3082575,CDM,301,RC,82575,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,9.46,100,,,fee schedule,Pays 100% Medicare OPPS,9.46,100,,,fee schedule,Pays 100% Medicare OPPS,9.46,100,,,fee schedule,Pays 100% Medicare OPPS,12.29,130,,,fee schedule,Pays 130% Medicare OPPS,14.3,120.37,,,fee schedule,120.37% of custom fee schedule,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.64,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,14.87,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,9.46,100,,,fee schedule,Pays 100% Medicare OPPS,8.51,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,14.3,120.37,,,fee schedule,120.37% of custom fee schedule,9.46,100,,,fee schedule,Pays 100% Medicare OPPS,12.29,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,9.46,100,,,fee schedule,Pays 100% Medicare OPPS,8.51,193.5,
Test to determine level of iron in the blood,3082728,CDM,301,RC,82728,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,13.63,100,,,fee schedule,Pays 100% Medicare OPPS,13.63,100,,,fee schedule,Pays 100% Medicare OPPS,13.63,100,,,fee schedule,Pays 100% Medicare OPPS,17.71,130,,,fee schedule,Pays 130% Medicare OPPS,20.62,120.37,,,fee schedule,120.37% of custom fee schedule,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.9,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,21.44,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,13.63,100,,,fee schedule,Pays 100% Medicare OPPS,12.26,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,20.62,120.37,,,fee schedule,120.37% of custom fee schedule,13.63,100,,,fee schedule,Pays 100% Medicare OPPS,17.71,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,13.63,100,,,fee schedule,Pays 100% Medicare OPPS,12.26,193.5,
FRUCTOSAMINE LEVEL,3082985,CDM,301,RC,82985,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,16.76,100,,,fee schedule,Pays 100% Medicare OPPS,16.76,100,,,fee schedule,Pays 100% Medicare OPPS,16.76,100,,,fee schedule,Pays 100% Medicare OPPS,21.78,130,,,fee schedule,Pays 130% Medicare OPPS,22.81,120.37,,,fee schedule,120.37% of custom fee schedule,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.09,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,23.72,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,16.76,100,,,fee schedule,Pays 100% Medicare OPPS,15.08,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,22.81,120.37,,,fee schedule,120.37% of custom fee schedule,16.76,100,,,fee schedule,Pays 100% Medicare OPPS,21.78,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,16.76,100,,,fee schedule,Pays 100% Medicare OPPS,15.08,193.5,
3RD PREGNENOLONE,3084140,CDM,302,RC,84140,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,20.67,100,,,fee schedule,Pays 100% Medicare OPPS,20.67,100,,,fee schedule,Pays 100% Medicare OPPS,20.67,100,,,fee schedule,Pays 100% Medicare OPPS,26.87,130,,,fee schedule,Pays 130% Medicare OPPS,31.3,120.37,,,fee schedule,120.37% of custom fee schedule,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,21.08,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,32.55,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,20.67,100,,,fee schedule,Pays 100% Medicare OPPS,18.6,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,31.3,120.37,,,fee schedule,120.37% of custom fee schedule,20.67,100,,,fee schedule,Pays 100% Medicare OPPS,26.87,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,20.67,100,,,fee schedule,Pays 100% Medicare OPPS,18.6,193.5,
THYROGLOBULIN PANEL,3084432,CDM,302,RC,84432,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,16.05,100,,,fee schedule,Pays 100% Medicare OPPS,16.05,100,,,fee schedule,Pays 100% Medicare OPPS,16.05,100,,,fee schedule,Pays 100% Medicare OPPS,20.87,130,,,fee schedule,Pays 130% Medicare OPPS,24.31,120.37,,,fee schedule,120.37% of custom fee schedule,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.38,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,25.29,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,16.05,100,,,fee schedule,Pays 100% Medicare OPPS,14.45,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,24.31,120.37,,,fee schedule,120.37% of custom fee schedule,16.05,100,,,fee schedule,Pays 100% Medicare OPPS,20.87,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,16.05,100,,,fee schedule,Pays 100% Medicare OPPS,14.45,193.5,
Blood test to evaluate thyroid function,3084439,CDM,301,RC,84439,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,9.02,100,,,fee schedule,Pays 100% Medicare OPPS,9.02,100,,,fee schedule,Pays 100% Medicare OPPS,9.02,100,,,fee schedule,Pays 100% Medicare OPPS,11.72,130,,,fee schedule,Pays 130% Medicare OPPS,13.65,120.37,,,fee schedule,120.37% of custom fee schedule,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.2,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,14.2,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,9.02,100,,,fee schedule,Pays 100% Medicare OPPS,8.11,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,13.65,120.37,,,fee schedule,120.37% of custom fee schedule,9.02,100,,,fee schedule,Pays 100% Medicare OPPS,11.72,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,9.02,100,,,fee schedule,Pays 100% Medicare OPPS,8.11,193.5,
UREA CLEARANCE,3084545,CDM,301,RC,84545,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,7.2,100,,,fee schedule,Pays 100% Medicare OPPS,7.2,100,,,fee schedule,Pays 100% Medicare OPPS,7.2,100,,,fee schedule,Pays 100% Medicare OPPS,9.36,130,,,fee schedule,Pays 130% Medicare OPPS,10,120.37,,,fee schedule,120.37% of custom fee schedule,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,7.34,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,10.4,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,7.2,100,,,fee schedule,Pays 100% Medicare OPPS,6.48,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,10,120.37,,,fee schedule,120.37% of custom fee schedule,7.2,100,,,fee schedule,Pays 100% Medicare OPPS,9.36,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,7.2,100,,,fee schedule,Pays 100% Medicare OPPS,6.48,193.5,
ZINC LEVEL,3084630,CDM,301,RC,84630,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,11.39,100,,,fee schedule,Pays 100% Medicare OPPS,11.39,100,,,fee schedule,Pays 100% Medicare OPPS,11.39,100,,,fee schedule,Pays 100% Medicare OPPS,14.8,130,,,fee schedule,Pays 130% Medicare OPPS,17.24,120.37,,,fee schedule,120.37% of custom fee schedule,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.61,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,17.93,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,11.39,100,,,fee schedule,Pays 100% Medicare OPPS,10.25,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,17.24,120.37,,,fee schedule,120.37% of custom fee schedule,11.39,100,,,fee schedule,Pays 100% Medicare OPPS,14.8,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,11.39,100,,,fee schedule,Pays 100% Medicare OPPS,10.25,193.5,
.FACTOR VIII ONE STAGE,3085240,CDM,305,RC,85240,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,17.89,100,,,fee schedule,Pays 100% Medicare OPPS,17.89,100,,,fee schedule,Pays 100% Medicare OPPS,17.89,100,,,fee schedule,Pays 100% Medicare OPPS,23.27,130,,,fee schedule,Pays 130% Medicare OPPS,27.11,120.37,,,fee schedule,120.37% of custom fee schedule,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.25,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,28.19,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,17.89,100,,,fee schedule,Pays 100% Medicare OPPS,16.1,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,27.11,120.37,,,fee schedule,120.37% of custom fee schedule,17.89,100,,,fee schedule,Pays 100% Medicare OPPS,23.27,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,17.89,100,,,fee schedule,Pays 100% Medicare OPPS,16.1,193.5,
".FACTOR VIII, VW FACTOR",3085245,CDM,305,RC,85245,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,22.94,100,,,fee schedule,Pays 100% Medicare OPPS,22.94,100,,,fee schedule,Pays 100% Medicare OPPS,22.94,100,,,fee schedule,Pays 100% Medicare OPPS,29.82,130,,,fee schedule,Pays 130% Medicare OPPS,34.73,120.37,,,fee schedule,120.37% of custom fee schedule,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,23.39,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,36.11,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,22.94,100,,,fee schedule,Pays 100% Medicare OPPS,20.64,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,34.73,120.37,,,fee schedule,120.37% of custom fee schedule,22.94,100,,,fee schedule,Pays 100% Medicare OPPS,29.82,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,22.94,100,,,fee schedule,Pays 100% Medicare OPPS,20.64,193.5,
FIBRINOGEN ACTIVITY,3085384,CDM,305,RC,85384,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,9.72,100,,,fee schedule,Pays 100% Medicare OPPS,9.72,100,,,fee schedule,Pays 100% Medicare OPPS,9.72,100,,,fee schedule,Pays 100% Medicare OPPS,12.63,130,,,fee schedule,Pays 130% Medicare OPPS,12.86,120.37,,,fee schedule,120.37% of custom fee schedule,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.91,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,13.37,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,9.72,100,,,fee schedule,Pays 100% Medicare OPPS,8.74,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,12.86,120.37,,,fee schedule,120.37% of custom fee schedule,9.72,100,,,fee schedule,Pays 100% Medicare OPPS,12.63,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,9.72,100,,,fee schedule,Pays 100% Medicare OPPS,8.74,193.5,
.PLATELET AGGREGATION,3085576,CDM,305,RC,85576,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,24.91,100,,,fee schedule,Pays 100% Medicare OPPS,24.91,100,,,fee schedule,Pays 100% Medicare OPPS,24.91,100,,,fee schedule,Pays 100% Medicare OPPS,32.38,130,,,fee schedule,Pays 130% Medicare OPPS,32.51,120.37,,,fee schedule,120.37% of custom fee schedule,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.4,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,33.81,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,24.91,100,,,fee schedule,Pays 100% Medicare OPPS,22.41,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,32.51,120.37,,,fee schedule,120.37% of custom fee schedule,24.91,100,,,fee schedule,Pays 100% Medicare OPPS,32.38,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,24.91,100,,,fee schedule,Pays 100% Medicare OPPS,22.41,193.5,
COLD AGGLUTININS,3086156,CDM,302,RC,86157,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,8.06,100,,,fee schedule,Pays 100% Medicare OPPS,8.06,100,,,fee schedule,Pays 100% Medicare OPPS,8.06,100,,,fee schedule,Pays 100% Medicare OPPS,10.47,130,,,fee schedule,Pays 130% Medicare OPPS,12.21,120.37,,,fee schedule,120.37% of custom fee schedule,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.22,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,12.69,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,8.06,100,,,fee schedule,Pays 100% Medicare OPPS,7.25,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,12.21,120.37,,,fee schedule,120.37% of custom fee schedule,8.06,100,,,fee schedule,Pays 100% Medicare OPPS,10.47,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,8.06,100,,,fee schedule,Pays 100% Medicare OPPS,7.25,193.5,
Blood test to diagnose mononucleosis,3086665,CDM,302,RC,86665,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,18.14,100,,,fee schedule,Pays 100% Medicare OPPS,18.14,100,,,fee schedule,Pays 100% Medicare OPPS,18.14,100,,,fee schedule,Pays 100% Medicare OPPS,23.58,130,,,fee schedule,Pays 130% Medicare OPPS,27.47,120.37,,,fee schedule,120.37% of custom fee schedule,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.5,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,28.57,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,18.14,100,,,fee schedule,Pays 100% Medicare OPPS,16.32,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,27.47,120.37,,,fee schedule,120.37% of custom fee schedule,18.14,100,,,fee schedule,Pays 100% Medicare OPPS,23.58,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,18.14,100,,,fee schedule,Pays 100% Medicare OPPS,16.32,193.5,
Blood test to determine existence of certain bacterium that causes syphilis,3086781,CDM,302,RC,86780,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,13.24,100,,,fee schedule,Pays 100% Medicare OPPS,13.24,100,,,fee schedule,Pays 100% Medicare OPPS,13.24,100,,,fee schedule,Pays 100% Medicare OPPS,17.21,130,,,fee schedule,Pays 130% Medicare OPPS,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.5,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,75.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,13.24,100,,,fee schedule,Pays 100% Medicare OPPS,11.91,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,13.24,100,,,fee schedule,Pays 100% Medicare OPPS,17.21,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,13.24,100,,,fee schedule,Pays 100% Medicare OPPS,11.91,193.5,
THYROGLOBULIN AB,3086800,CDM,302,RC,86800,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,15.91,100,,,fee schedule,Pays 100% Medicare OPPS,15.91,100,,,fee schedule,Pays 100% Medicare OPPS,15.91,100,,,fee schedule,Pays 100% Medicare OPPS,20.68,130,,,fee schedule,Pays 130% Medicare OPPS,24.07,120.37,,,fee schedule,120.37% of custom fee schedule,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.22,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,25.04,125.18,,,fee schedule,125.18% of custom fee schedule,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,15.91,100,,,fee schedule,Pays 100% Medicare OPPS,14.31,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,24.07,120.37,,,fee schedule,120.37% of custom fee schedule,15.91,100,,,fee schedule,Pays 100% Medicare OPPS,20.68,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,15.91,100,,,fee schedule,Pays 100% Medicare OPPS,14.31,193.5,
.INCUBATION (X-M),3086921,CDM,300,RC,86921,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,179.8,130,,,fee schedule,Pays 130% Medicare OPPS,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,136.65,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,75.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,120.57,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,138.31,100,,,fee schedule,Pays 100% Medicare OPPS,179.8,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,43.8,193.5,
XR SIALOGRAPHY SET,4070391,CDM,270,RC,,,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,193.5,90,,,percent of total billed charges,90% of total billed charges,75.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,124.7,58,,,percent of total billed charges,58% of total billed charges,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,182.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,43.8,193.5,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",4090776,CDM,760,RC,96376,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,193.5,90,,,percent of total billed charges,90% of total billed charges,75.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,124.7,58,,,percent of total billed charges,58% of total billed charges,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,182.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,43.8,193.5,
OT ORTHOTIC TRAIN/FAB (PER 15 MINS),5197760,CDM,430,RC,97760,HCPCS,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,45.88,100,,,fee schedule,Pays 100% Medicare OPPS,45.88,100,,,fee schedule,Pays 100% Medicare OPPS,45.88,100,,,fee schedule,Pays 100% Medicare OPPS,58.96,130,,,fee schedule,Pays 130% Medicare OPPS,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,46.8,102,,,fee schedule,Pays 102% Medicare OPPS,193.5,90,,,percent of total billed charges,90% of total billed charges,75.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,45.88,100,,,fee schedule,Pays 100% Medicare OPPS,41.29,90,,,fee schedule,Pays 90% Medicare OPPS,124.7,58,,,percent of total billed charges,58% of total billed charges,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,45.35,100,,,fee schedule,Pays 100% Medicare OPPS,58.96,130,,,fee schedule,Pays 130% Medicare OPPS,182.75,85,,,percent of total billed charges,85% of total billed charges,45.88,100,,,fee schedule,Pays 100% Medicare OPPS,41.29,193.5,
LECTROVAC II 12 FR,7905767,CDM,270,RC,,,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,193.5,90,,,percent of total billed charges,90% of total billed charges,75.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,124.7,58,,,percent of total billed charges,58% of total billed charges,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,182.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,43.8,193.5,
LIGACLIP CLIP APPLIER MCS20,7950138,CDM,272,RC,,,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,193.5,90,,,percent of total billed charges,90% of total billed charges,75.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,124.7,58,,,percent of total billed charges,58% of total billed charges,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,182.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,43.8,193.5,
ENDO POUCH RETRIEVER (POUCH),7950144,CDM,272,RC,,,Outpatient,,,215,172,,182.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,121.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,193.5,90,,,percent of total billed charges,90% of total billed charges,75.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,147.71,68.7,,,percent of total billed charges,68.7% of total billed charges,172,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,124.7,58,,,percent of total billed charges,58% of total billed charges,43.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,182.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,43.8,193.5,
LIGATOR SHORTSHOT SAEED MULTI-BAND,1750016,CDM,270,RC,,,Outpatient,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,44.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,198,90,,,percent of total billed charges,90% of total billed charges,77,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,127.6,58,,,percent of total billed charges,58% of total billed charges,44.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,187,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,44.81,198,
NF-RONDEC DROPS (CARBINOXAMINE/PSE) DROP,2600870,CDM,637,RC,,,Outpatient,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,44.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,198,90,,,percent of total billed charges,90% of total billed charges,77,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,127.6,58,,,percent of total billed charges,58% of total billed charges,44.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,187,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,44.81,198,
ROCEPHIN INJ (CEFTRIAXONE NA) 1GM,2601060,CDM,636,RC,J0696,HCPCS,Both,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,0.6,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,198,90,,,percent of total billed charges,90% of total billed charges,0.63,125.18,,,fee schedule,125.18% of custom fee schedule,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,127.6,58,,,percent of total billed charges,58% of total billed charges,0.6,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,187,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.6,198,
ZITHROMAX INJ 500MG,2602338,CDM,636,RC,J0456,HCPCS,Both,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,44.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,198,90,,,percent of total billed charges,90% of total billed charges,77,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,127.6,58,,,percent of total billed charges,58% of total billed charges,44.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,187,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,44.81,198,
BRETHINE (TERBUTALINE SULF) INJ 1MG,2602535,CDM,636,RC,J3105,HCPCS,Both,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,15.37,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,198,90,,,percent of total billed charges,90% of total billed charges,15.99,125.18,,,fee schedule,125.18% of custom fee schedule,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,127.6,58,,,percent of total billed charges,58% of total billed charges,15.37,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,187,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,15.37,198,
SYNTHROID (LEVOTHYROXINE) INJECT 200MCG,2602831,CDM,637,RC,,,Outpatient,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,44.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,198,90,,,percent of total billed charges,90% of total billed charges,77,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,127.6,58,,,percent of total billed charges,58% of total billed charges,44.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,187,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,44.81,198,
SCLERODERMA ANTIBODIES,3000278,CDM,302,RC,86235,HCPCS,Outpatient,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.28,102,,,fee schedule,Pays 102% Medicare OPPS,198,90,,,percent of total billed charges,90% of total billed charges,28.23,125.18,,,fee schedule,125.18% of custom fee schedule,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,90,,,fee schedule,Pays 90% Medicare OPPS,127.6,58,,,percent of total billed charges,58% of total billed charges,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,187,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,198,
Test of body fluid other than blood to assess for bacteria,3000351,CDM,306,RC,87070,HCPCS,Outpatient,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.2,130,,,fee schedule,Pays 130% Medicare OPPS,13.04,120.37,,,fee schedule,120.37% of custom fee schedule,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.79,102,,,fee schedule,Pays 102% Medicare OPPS,198,90,,,percent of total billed charges,90% of total billed charges,13.56,125.18,,,fee schedule,125.18% of custom fee schedule,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,7.75,90,,,fee schedule,Pays 90% Medicare OPPS,127.6,58,,,percent of total billed charges,58% of total billed charges,13.04,120.37,,,fee schedule,120.37% of custom fee schedule,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.2,130,,,fee schedule,Pays 130% Medicare OPPS,187,85,,,percent of total billed charges,85% of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,7.75,198,
Medical test to find an infection,3000376,CDM,306,RC,87081,HCPCS,Outpatient,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,6.63,100,,,fee schedule,Pays 100% Medicare OPPS,6.63,100,,,fee schedule,Pays 100% Medicare OPPS,6.63,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,130,,,fee schedule,Pays 130% Medicare OPPS,10.03,120.37,,,fee schedule,120.37% of custom fee schedule,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.76,102,,,fee schedule,Pays 102% Medicare OPPS,198,90,,,percent of total billed charges,90% of total billed charges,10.43,125.18,,,fee schedule,125.18% of custom fee schedule,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,6.63,100,,,fee schedule,Pays 100% Medicare OPPS,5.96,90,,,fee schedule,Pays 90% Medicare OPPS,127.6,58,,,percent of total billed charges,58% of total billed charges,10.03,120.37,,,fee schedule,120.37% of custom fee schedule,6.63,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,130,,,fee schedule,Pays 130% Medicare OPPS,187,85,,,percent of total billed charges,85% of total billed charges,6.63,100,,,fee schedule,Pays 100% Medicare OPPS,5.96,198,
COPPER LEVEL 24 HR URINE,3000395,CDM,301,RC,82525,HCPCS,Outpatient,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,12.41,100,,,fee schedule,Pays 100% Medicare OPPS,12.41,100,,,fee schedule,Pays 100% Medicare OPPS,12.41,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,130,,,fee schedule,Pays 130% Medicare OPPS,18.79,120.37,,,fee schedule,120.37% of custom fee schedule,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.65,102,,,fee schedule,Pays 102% Medicare OPPS,198,90,,,percent of total billed charges,90% of total billed charges,19.54,125.18,,,fee schedule,125.18% of custom fee schedule,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,12.41,100,,,fee schedule,Pays 100% Medicare OPPS,11.16,90,,,fee schedule,Pays 90% Medicare OPPS,127.6,58,,,percent of total billed charges,58% of total billed charges,18.79,120.37,,,fee schedule,120.37% of custom fee schedule,12.41,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,130,,,fee schedule,Pays 130% Medicare OPPS,187,85,,,percent of total billed charges,85% of total billed charges,12.41,100,,,fee schedule,Pays 100% Medicare OPPS,11.16,198,
Test that detects Chlamydia,3000550,CDM,300,RC,87491,HCPCS,Outpatient,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,,,fee schedule,Pays 130% Medicare OPPS,29.7,120.37,,,fee schedule,120.37% of custom fee schedule,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,35.79,102,,,fee schedule,Pays 102% Medicare OPPS,198,90,,,percent of total billed charges,90% of total billed charges,30.88,125.18,,,fee schedule,125.18% of custom fee schedule,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,31.58,90,,,fee schedule,Pays 90% Medicare OPPS,127.6,58,,,percent of total billed charges,58% of total billed charges,29.7,120.37,,,fee schedule,120.37% of custom fee schedule,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,,,fee schedule,Pays 130% Medicare OPPS,187,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,29.7,198,
Blood test for an STD,3000551,CDM,300,RC,87591,HCPCS,Outpatient,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,,,fee schedule,Pays 130% Medicare OPPS,25.78,120.37,,,fee schedule,120.37% of custom fee schedule,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,35.79,102,,,fee schedule,Pays 102% Medicare OPPS,198,90,,,percent of total billed charges,90% of total billed charges,26.81,125.18,,,fee schedule,125.18% of custom fee schedule,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,31.58,90,,,fee schedule,Pays 90% Medicare OPPS,127.6,58,,,percent of total billed charges,58% of total billed charges,25.78,120.37,,,fee schedule,120.37% of custom fee schedule,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,,,fee schedule,Pays 130% Medicare OPPS,187,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,25.78,198,
ALPHA-FETOPROTEIN BODY FLUID,3000607,CDM,300,RC,82106,HCPCS,Outpatient,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,17,100,,,fee schedule,Pays 100% Medicare OPPS,17,100,,,fee schedule,Pays 100% Medicare OPPS,17,100,,,fee schedule,Pays 100% Medicare OPPS,22.1,130,,,fee schedule,Pays 130% Medicare OPPS,25.4,120.37,,,fee schedule,120.37% of custom fee schedule,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.34,102,,,fee schedule,Pays 102% Medicare OPPS,198,90,,,percent of total billed charges,90% of total billed charges,26.41,125.18,,,fee schedule,125.18% of custom fee schedule,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,17,100,,,fee schedule,Pays 100% Medicare OPPS,15.3,90,,,fee schedule,Pays 90% Medicare OPPS,127.6,58,,,percent of total billed charges,58% of total billed charges,25.4,120.37,,,fee schedule,120.37% of custom fee schedule,17,100,,,fee schedule,Pays 100% Medicare OPPS,22.1,130,,,fee schedule,Pays 130% Medicare OPPS,187,85,,,percent of total billed charges,85% of total billed charges,17,100,,,fee schedule,Pays 100% Medicare OPPS,15.3,198,
3RD BORDTELLA PERTUSSIS IGM,3000615,CDM,301,RC,86615,HCPCS,Outpatient,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,17.14,130,,,fee schedule,Pays 130% Medicare OPPS,19.97,120.37,,,fee schedule,120.37% of custom fee schedule,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.45,102,,,fee schedule,Pays 102% Medicare OPPS,198,90,,,percent of total billed charges,90% of total billed charges,20.77,125.18,,,fee schedule,125.18% of custom fee schedule,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,11.87,90,,,fee schedule,Pays 90% Medicare OPPS,127.6,58,,,percent of total billed charges,58% of total billed charges,19.97,120.37,,,fee schedule,120.37% of custom fee schedule,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,17.14,130,,,fee schedule,Pays 130% Medicare OPPS,187,85,,,percent of total billed charges,85% of total billed charges,13.19,100,,,fee schedule,Pays 100% Medicare OPPS,11.87,198,
Medical test to find an infection,3000616,CDM,301,RC,87081,HCPCS,Outpatient,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,6.63,100,,,fee schedule,Pays 100% Medicare OPPS,6.63,100,,,fee schedule,Pays 100% Medicare OPPS,6.63,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,130,,,fee schedule,Pays 130% Medicare OPPS,10.03,120.37,,,fee schedule,120.37% of custom fee schedule,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.76,102,,,fee schedule,Pays 102% Medicare OPPS,198,90,,,percent of total billed charges,90% of total billed charges,10.43,125.18,,,fee schedule,125.18% of custom fee schedule,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,6.63,100,,,fee schedule,Pays 100% Medicare OPPS,5.96,90,,,fee schedule,Pays 90% Medicare OPPS,127.6,58,,,percent of total billed charges,58% of total billed charges,10.03,120.37,,,fee schedule,120.37% of custom fee schedule,6.63,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,130,,,fee schedule,Pays 130% Medicare OPPS,187,85,,,percent of total billed charges,85% of total billed charges,6.63,100,,,fee schedule,Pays 100% Medicare OPPS,5.96,198,
COPPER LEVEL,3082525,CDM,301,RC,82525,HCPCS,Outpatient,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,12.41,100,,,fee schedule,Pays 100% Medicare OPPS,12.41,100,,,fee schedule,Pays 100% Medicare OPPS,12.41,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,130,,,fee schedule,Pays 130% Medicare OPPS,18.79,120.37,,,fee schedule,120.37% of custom fee schedule,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.65,102,,,fee schedule,Pays 102% Medicare OPPS,198,90,,,percent of total billed charges,90% of total billed charges,19.54,125.18,,,fee schedule,125.18% of custom fee schedule,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,12.41,100,,,fee schedule,Pays 100% Medicare OPPS,11.16,90,,,fee schedule,Pays 90% Medicare OPPS,127.6,58,,,percent of total billed charges,58% of total billed charges,18.79,120.37,,,fee schedule,120.37% of custom fee schedule,12.41,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,130,,,fee schedule,Pays 130% Medicare OPPS,187,85,,,percent of total billed charges,85% of total billed charges,12.41,100,,,fee schedule,Pays 100% Medicare OPPS,11.16,198,
.LIPOPROTEIN BKDWN;HI RESO,3083701,CDM,300,RC,83701,HCPCS,Outpatient,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,33.86,100,,,fee schedule,Pays 100% Medicare OPPS,33.86,100,,,fee schedule,Pays 100% Medicare OPPS,33.86,100,,,fee schedule,Pays 100% Medicare OPPS,44.01,130,,,fee schedule,Pays 130% Medicare OPPS,37.57,120.37,,,fee schedule,120.37% of custom fee schedule,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,34.53,102,,,fee schedule,Pays 102% Medicare OPPS,198,90,,,percent of total billed charges,90% of total billed charges,39.07,125.18,,,fee schedule,125.18% of custom fee schedule,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,33.86,100,,,fee schedule,Pays 100% Medicare OPPS,30.47,90,,,fee schedule,Pays 90% Medicare OPPS,127.6,58,,,percent of total billed charges,58% of total billed charges,37.57,120.37,,,fee schedule,120.37% of custom fee schedule,33.86,100,,,fee schedule,Pays 100% Medicare OPPS,44.01,130,,,fee schedule,Pays 130% Medicare OPPS,187,85,,,percent of total billed charges,85% of total billed charges,33.86,100,,,fee schedule,Pays 100% Medicare OPPS,30.47,198,
VITAMIN B6,3084207,CDM,301,RC,84207,HCPCS,Outpatient,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,28.1,100,,,fee schedule,Pays 100% Medicare OPPS,28.1,100,,,fee schedule,Pays 100% Medicare OPPS,28.1,100,,,fee schedule,Pays 100% Medicare OPPS,36.53,130,,,fee schedule,Pays 130% Medicare OPPS,42.53,120.37,,,fee schedule,120.37% of custom fee schedule,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.66,102,,,fee schedule,Pays 102% Medicare OPPS,198,90,,,percent of total billed charges,90% of total billed charges,44.23,125.18,,,fee schedule,125.18% of custom fee schedule,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,28.1,100,,,fee schedule,Pays 100% Medicare OPPS,25.29,90,,,fee schedule,Pays 90% Medicare OPPS,127.6,58,,,percent of total billed charges,58% of total billed charges,42.53,120.37,,,fee schedule,120.37% of custom fee schedule,28.1,100,,,fee schedule,Pays 100% Medicare OPPS,36.53,130,,,fee schedule,Pays 130% Medicare OPPS,187,85,,,percent of total billed charges,85% of total billed charges,28.1,100,,,fee schedule,Pays 100% Medicare OPPS,25.29,198,
Blood test to screen for antibodies that could harm red blood cells,3086850,CDM,300,RC,86850,HCPCS,Outpatient,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,57.33,130,,,fee schedule,Pays 130% Medicare OPPS,18.33,120.37,,,fee schedule,120.37% of custom fee schedule,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.53,102,,,fee schedule,Pays 102% Medicare OPPS,198,90,,,percent of total billed charges,90% of total billed charges,19.06,125.18,,,fee schedule,125.18% of custom fee schedule,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,40.17,90,,,fee schedule,Pays 90% Medicare OPPS,127.6,58,,,percent of total billed charges,58% of total billed charges,18.33,120.37,,,fee schedule,120.37% of custom fee schedule,44.1,100,,,fee schedule,Pays 100% Medicare OPPS,57.33,130,,,fee schedule,Pays 130% Medicare OPPS,187,85,,,percent of total billed charges,85% of total billed charges,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,18.33,198,
INDIRECT COOMBS,3086886,CDM,300,RC,86886,HCPCS,Outpatient,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,179.8,130,,,fee schedule,Pays 130% Medicare OPPS,7.04,120.37,,,fee schedule,120.37% of custom fee schedule,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,136.65,102,,,fee schedule,Pays 102% Medicare OPPS,198,90,,,percent of total billed charges,90% of total billed charges,7.32,125.18,,,fee schedule,125.18% of custom fee schedule,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,120.57,90,,,fee schedule,Pays 90% Medicare OPPS,127.6,58,,,percent of total billed charges,58% of total billed charges,7.04,120.37,,,fee schedule,120.37% of custom fee schedule,138.31,100,,,fee schedule,Pays 100% Medicare OPPS,179.8,130,,,fee schedule,Pays 130% Medicare OPPS,187,85,,,percent of total billed charges,85% of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,7.04,198,
Medical test to find an infection,3087081,CDM,306,RC,87081,HCPCS,Outpatient,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,6.63,100,,,fee schedule,Pays 100% Medicare OPPS,6.63,100,,,fee schedule,Pays 100% Medicare OPPS,6.63,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,130,,,fee schedule,Pays 130% Medicare OPPS,10.03,120.37,,,fee schedule,120.37% of custom fee schedule,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.76,102,,,fee schedule,Pays 102% Medicare OPPS,198,90,,,percent of total billed charges,90% of total billed charges,10.43,125.18,,,fee schedule,125.18% of custom fee schedule,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,6.63,100,,,fee schedule,Pays 100% Medicare OPPS,5.96,90,,,fee schedule,Pays 90% Medicare OPPS,127.6,58,,,percent of total billed charges,58% of total billed charges,10.03,120.37,,,fee schedule,120.37% of custom fee schedule,6.63,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,130,,,fee schedule,Pays 130% Medicare OPPS,187,85,,,percent of total billed charges,85% of total billed charges,6.63,100,,,fee schedule,Pays 100% Medicare OPPS,5.96,198,
Culture of the urine to determine number of bacteria,3087086,CDM,306,RC,87086,HCPCS,Outpatient,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,8.07,100,,,fee schedule,Pays 100% Medicare OPPS,8.07,100,,,fee schedule,Pays 100% Medicare OPPS,8.07,100,,,fee schedule,Pays 100% Medicare OPPS,10.49,130,,,fee schedule,Pays 130% Medicare OPPS,12.22,120.37,,,fee schedule,120.37% of custom fee schedule,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.23,102,,,fee schedule,Pays 102% Medicare OPPS,198,90,,,percent of total billed charges,90% of total billed charges,12.71,125.18,,,fee schedule,125.18% of custom fee schedule,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,8.07,100,,,fee schedule,Pays 100% Medicare OPPS,7.26,90,,,fee schedule,Pays 90% Medicare OPPS,127.6,58,,,percent of total billed charges,58% of total billed charges,12.22,120.37,,,fee schedule,120.37% of custom fee schedule,8.07,100,,,fee schedule,Pays 100% Medicare OPPS,10.49,130,,,fee schedule,Pays 130% Medicare OPPS,187,85,,,percent of total billed charges,85% of total billed charges,8.07,100,,,fee schedule,Pays 100% Medicare OPPS,7.26,198,
Blood test for an STD,3087661,CDM,300,RC,87661,HCPCS,Outpatient,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,,,fee schedule,Pays 130% Medicare OPPS,25.78,120.37,,,fee schedule,120.37% of custom fee schedule,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,35.79,102,,,fee schedule,Pays 102% Medicare OPPS,198,90,,,percent of total billed charges,90% of total billed charges,26.81,125.18,,,fee schedule,125.18% of custom fee schedule,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,31.58,90,,,fee schedule,Pays 90% Medicare OPPS,127.6,58,,,percent of total billed charges,58% of total billed charges,25.78,120.37,,,fee schedule,120.37% of custom fee schedule,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,,,fee schedule,Pays 130% Medicare OPPS,187,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,25.78,198,
Outpatient visit of established patient not requiring a physician,4099211,CDM,761,RC,99211,HCPCS,Outpatient,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,44.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,198,90,,,percent of total billed charges,90% of total billed charges,77,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,127.6,58,,,percent of total billed charges,58% of total billed charges,44.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,187,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,44.81,198,
CATH CHOLANGIOGRAM,7905270,CDM,270,RC,,,Outpatient,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,44.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,198,90,,,percent of total billed charges,90% of total billed charges,77,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,127.6,58,,,percent of total billed charges,58% of total billed charges,44.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,187,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,44.81,198,
TRACHEOSTOMY TUBE SZ 4 DFEN,7905574,CDM,272,RC,,,Outpatient,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,44.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,198,90,,,percent of total billed charges,90% of total billed charges,77,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,127.6,58,,,percent of total billed charges,58% of total billed charges,44.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,187,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,44.81,198,
TRACHEOSTOMY TUBE SZ 8DFEN,7905577,CDM,272,RC,,,Outpatient,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,44.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,198,90,,,percent of total billed charges,90% of total billed charges,77,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,127.6,58,,,percent of total billed charges,58% of total billed charges,44.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,187,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,44.81,198,
SKIN STAPLER,7950068,CDM,272,RC,,,Outpatient,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,44.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,198,90,,,percent of total billed charges,90% of total billed charges,77,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,127.6,58,,,percent of total billed charges,58% of total billed charges,44.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,187,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,44.81,198,
CATH PED FOLEY,7950163,CDM,270,RC,,,Outpatient,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,44.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,198,90,,,percent of total billed charges,90% of total billed charges,77,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,127.6,58,,,percent of total billed charges,58% of total billed charges,44.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,187,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,44.81,198,
BIOPSY INSTRUMENT MONOPTY 121810,7950207,CDM,270,RC,,,Outpatient,,,220,176,,187,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,44.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,124.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,198,90,,,percent of total billed charges,90% of total billed charges,77,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,151.14,68.7,,,percent of total billed charges,68.7% of total billed charges,176,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,127.6,58,,,percent of total billed charges,58% of total billed charges,44.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,187,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,44.81,198,
VOLTAREN (DICLOFENAC) OPHTH DROP,2602225,CDM,637,RC,,,Outpatient,,,225,180,,191.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,45.83,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,127.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,127.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,127.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,127.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,202.5,90,,,percent of total billed charges,90% of total billed charges,78.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,154.58,68.7,,,percent of total billed charges,68.7% of total billed charges,180,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,130.5,58,,,percent of total billed charges,58% of total billed charges,45.83,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,191.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,45.83,202.5,
ANTI DIURETIC HORMONE,3084588,CDM,302,RC,84588,HCPCS,Outpatient,,,225,180,,191.25,85,,,percent of total billed charges,85% of total billed charges,33.94,100,,,fee schedule,Pays 100% Medicare OPPS,33.94,100,,,fee schedule,Pays 100% Medicare OPPS,33.94,100,,,fee schedule,Pays 100% Medicare OPPS,44.12,130,,,fee schedule,Pays 130% Medicare OPPS,51.39,120.37,,,fee schedule,120.37% of custom fee schedule,127.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,127.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,127.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,127.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,34.61,102,,,fee schedule,Pays 102% Medicare OPPS,202.5,90,,,percent of total billed charges,90% of total billed charges,53.44,125.18,,,fee schedule,125.18% of custom fee schedule,154.58,68.7,,,percent of total billed charges,68.7% of total billed charges,180,80,,,percent of total billed charges,80 percent of total billed charges,33.94,100,,,fee schedule,Pays 100% Medicare OPPS,30.54,90,,,fee schedule,Pays 90% Medicare OPPS,130.5,58,,,percent of total billed charges,58% of total billed charges,51.39,120.37,,,fee schedule,120.37% of custom fee schedule,33.94,100,,,fee schedule,Pays 100% Medicare OPPS,44.12,130,,,fee schedule,Pays 130% Medicare OPPS,191.25,85,,,percent of total billed charges,85% of total billed charges,33.94,100,,,fee schedule,Pays 100% Medicare OPPS,30.54,202.5,
SHOULDER STABILIZATION KIT,1570856,CDM,272,RC,,,Outpatient,,,227.4,181.92,,193.29,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,46.32,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,128.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,128.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,128.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,128.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,204.66,90,,,percent of total billed charges,90% of total billed charges,79.59,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,156.22,68.7,,,percent of total billed charges,68.7% of total billed charges,181.92,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,131.89,58,,,percent of total billed charges,58% of total billed charges,46.32,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,193.29,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,46.32,204.66,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",1090775,CDM,760,RC,96375,HCPCS,Outpatient,,,235,188,,199.75,85,,,percent of total billed charges,85% of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.65,102,,,fee schedule,Pays 102% Medicare OPPS,211.5,90,,,percent of total billed charges,90% of total billed charges,82.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,161.45,68.7,,,percent of total billed charges,68.7% of total billed charges,188,80,,,percent of total billed charges,80 percent of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,90,,,fee schedule,Pays 90% Medicare OPPS,136.3,58,,,percent of total billed charges,58% of total billed charges,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,37.26,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,199.75,85,,,percent of total billed charges,85% of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,211.5,
OR ACUITY LEVEL 1-A X 15 MIN,1501148,CDM,360,RC,,,Outpatient,,,235,188,,199.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,211.5,90,,,percent of total billed charges,90% of total billed charges,82.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,161.45,68.7,,,percent of total billed charges,68.7% of total billed charges,188,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,136.3,58,,,percent of total billed charges,58% of total billed charges,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,199.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,47.87,211.5,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",1590775,CDM,760,RC,96375,HCPCS,Outpatient,,,235,188,,199.75,85,,,percent of total billed charges,85% of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.65,102,,,fee schedule,Pays 102% Medicare OPPS,211.5,90,,,percent of total billed charges,90% of total billed charges,82.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,161.45,68.7,,,percent of total billed charges,68.7% of total billed charges,188,80,,,percent of total billed charges,80 percent of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,90,,,fee schedule,Pays 90% Medicare OPPS,136.3,58,,,percent of total billed charges,58% of total billed charges,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,37.26,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,199.75,85,,,percent of total billed charges,85% of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,211.5,
FX NOSE CLOSED,2021310,CDM,450,RC,21310,HCPCS,Outpatient,,,235,188,,199.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,211.5,90,,,percent of total billed charges,90% of total billed charges,82.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,161.45,68.7,,,percent of total billed charges,68.7% of total billed charges,188,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,136.3,58,,,percent of total billed charges,58% of total billed charges,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,199.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,47.87,211.5,
FB REMOVAL MOUTH,2040804,CDM,450,RC,40804,HCPCS,Outpatient,,,235,188,,199.75,85,,,percent of total billed charges,85% of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,943.93,130,,,fee schedule,Pays 130% Medicare OPPS,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,741.41,102,,,fee schedule,Pays 102% Medicare OPPS,211.5,90,,,percent of total billed charges,90% of total billed charges,82.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,161.45,68.7,,,percent of total billed charges,68.7% of total billed charges,188,80,,,percent of total billed charges,80 percent of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,654.18,90,,,fee schedule,Pays 90% Medicare OPPS,136.3,58,,,percent of total billed charges,58% of total billed charges,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,726.1,100,,,fee schedule,Pays 100% Medicare OPPS,943.93,130,,,fee schedule,Pays 130% Medicare OPPS,199.75,85,,,percent of total billed charges,85% of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,47.87,943.93,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",2090775,CDM,450,RC,96375,HCPCS,Outpatient,,,235,188,,199.75,85,,,percent of total billed charges,85% of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.65,102,,,fee schedule,Pays 102% Medicare OPPS,211.5,90,,,percent of total billed charges,90% of total billed charges,82.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,161.45,68.7,,,percent of total billed charges,68.7% of total billed charges,188,80,,,percent of total billed charges,80 percent of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,90,,,fee schedule,Pays 90% Medicare OPPS,136.3,58,,,percent of total billed charges,58% of total billed charges,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,37.26,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,199.75,85,,,percent of total billed charges,85% of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,211.5,
FORANE (ISOFLURANE) GAS,2600048,CDM,250,RC,,,Outpatient,,,235,188,,199.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,211.5,90,,,percent of total billed charges,90% of total billed charges,82.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,161.45,68.7,,,percent of total billed charges,68.7% of total billed charges,188,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,136.3,58,,,percent of total billed charges,58% of total billed charges,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,199.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,47.87,211.5,
PROVENTIL (ALBUTEROL) HFA INHALER,2600162,CDM,250,RC,,,Outpatient,,,235,188,,199.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,211.5,90,,,percent of total billed charges,90% of total billed charges,82.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,161.45,68.7,,,percent of total billed charges,68.7% of total billed charges,188,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,136.3,58,,,percent of total billed charges,58% of total billed charges,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,199.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,47.87,211.5,
DEPO-ESTRADIOL (ESTRADIOL CYP) INJ 5MG,2601293,CDM,636,RC,,,Both,,,235,188,,199.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,211.5,90,,,percent of total billed charges,90% of total billed charges,82.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,161.45,68.7,,,percent of total billed charges,68.7% of total billed charges,188,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,136.3,58,,,percent of total billed charges,58% of total billed charges,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,199.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,47.87,211.5,
AZITHROMYCIN SUSP 200MG/5ML 30ML,2602258,CDM,637,RC,Q0144,HCPCS,Outpatient,,,235,188,,199.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,211.5,90,,,percent of total billed charges,90% of total billed charges,82.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,161.45,68.7,,,percent of total billed charges,68.7% of total billed charges,188,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,136.3,58,,,percent of total billed charges,58% of total billed charges,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,199.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,47.87,211.5,
NON-FORMULARY INHALER,2602290,CDM,250,RC,,,Outpatient,,,235,188,,199.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,211.5,90,,,percent of total billed charges,90% of total billed charges,82.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,161.45,68.7,,,percent of total billed charges,68.7% of total billed charges,188,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,136.3,58,,,percent of total billed charges,58% of total billed charges,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,199.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,47.87,211.5,
FLUOTHANE (HALOTHANE) GAS,2605004,CDM,250,RC,,,Outpatient,,,235,188,,199.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,211.5,90,,,percent of total billed charges,90% of total billed charges,82.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,161.45,68.7,,,percent of total billed charges,68.7% of total billed charges,188,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,136.3,58,,,percent of total billed charges,58% of total billed charges,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,199.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,47.87,211.5,
AA 4.25% DEX 10% c LYTES : 1000ML,2611007,CDM,250,RC,,,Outpatient,,,235,188,,199.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,211.5,90,,,percent of total billed charges,90% of total billed charges,82.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,161.45,68.7,,,percent of total billed charges,68.7% of total billed charges,188,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,136.3,58,,,percent of total billed charges,58% of total billed charges,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,199.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,47.87,211.5,
AA 4.25% DEX 25% c LYTES : 1000ML,2611008,CDM,250,RC,,,Outpatient,,,235,188,,199.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,211.5,90,,,percent of total billed charges,90% of total billed charges,82.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,161.45,68.7,,,percent of total billed charges,68.7% of total billed charges,188,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,136.3,58,,,percent of total billed charges,58% of total billed charges,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,199.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,47.87,211.5,
MIOCHOL-E (A-CHOLINE) INTRAOCULAR 1KIT,2660019,CDM,636,RC,,,Both,,,235,188,,199.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,211.5,90,,,percent of total billed charges,90% of total billed charges,82.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,161.45,68.7,,,percent of total billed charges,68.7% of total billed charges,188,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,136.3,58,,,percent of total billed charges,58% of total billed charges,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,199.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,47.87,211.5,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",4090775,CDM,760,RC,96375,HCPCS,Outpatient,,,235,188,,199.75,85,,,percent of total billed charges,85% of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.65,102,,,fee schedule,Pays 102% Medicare OPPS,211.5,90,,,percent of total billed charges,90% of total billed charges,82.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,161.45,68.7,,,percent of total billed charges,68.7% of total billed charges,188,80,,,percent of total billed charges,80 percent of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,90,,,fee schedule,Pays 90% Medicare OPPS,136.3,58,,,percent of total billed charges,58% of total billed charges,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,37.26,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,199.75,85,,,percent of total billed charges,85% of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,211.5,
PT CANALITH REPOSITIONING PROCEDURE,5095992,CDM,420,RC,95992,HCPCS,Outpatient,,,235,188,,199.75,85,,,percent of total billed charges,85% of total billed charges,42.09,100,,,fee schedule,Pays 100% Medicare OPPS,42.09,100,,,fee schedule,Pays 100% Medicare OPPS,42.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.7,130,,,fee schedule,Pays 130% Medicare OPPS,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.93,102,,,fee schedule,Pays 102% Medicare OPPS,211.5,90,,,percent of total billed charges,90% of total billed charges,82.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,161.45,68.7,,,percent of total billed charges,68.7% of total billed charges,188,80,,,percent of total billed charges,80 percent of total billed charges,42.09,100,,,fee schedule,Pays 100% Medicare OPPS,37.88,90,,,fee schedule,Pays 90% Medicare OPPS,136.3,58,,,percent of total billed charges,58% of total billed charges,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,35.15,100,,,fee schedule,Pays 100% Medicare OPPS,45.7,130,,,fee schedule,Pays 130% Medicare OPPS,199.75,85,,,percent of total billed charges,85% of total billed charges,42.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.15,211.5,
INDIV DM/HYPO SELF MGMT,6000844,CDM,942,RC,,,Outpatient,,,235,188,,199.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,211.5,90,,,percent of total billed charges,90% of total billed charges,82.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,161.45,68.7,,,percent of total billed charges,68.7% of total billed charges,188,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,136.3,58,,,percent of total billed charges,58% of total billed charges,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,199.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,47.87,211.5,
FORCEP BIOPSY DISP. FB220K.A,7905048,CDM,272,RC,,,Outpatient,,,235,188,,199.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,211.5,90,,,percent of total billed charges,90% of total billed charges,82.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,161.45,68.7,,,percent of total billed charges,68.7% of total billed charges,188,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,136.3,58,,,percent of total billed charges,58% of total billed charges,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,199.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,47.87,211.5,
FORCEP BIOPSY DISP. FB220U.A,7905049,CDM,272,RC,,,Outpatient,,,235,188,,199.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,211.5,90,,,percent of total billed charges,90% of total billed charges,82.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,161.45,68.7,,,percent of total billed charges,68.7% of total billed charges,188,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,136.3,58,,,percent of total billed charges,58% of total billed charges,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,199.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,47.87,211.5,
GASTRIC LAVAGE KIT,7905245,CDM,270,RC,,,Outpatient,,,235,188,,199.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,211.5,90,,,percent of total billed charges,90% of total billed charges,82.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,161.45,68.7,,,percent of total billed charges,68.7% of total billed charges,188,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,136.3,58,,,percent of total billed charges,58% of total billed charges,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,199.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,47.87,211.5,
EXTREMITY T-SHEET,7905567,CDM,270,RC,,,Outpatient,,,235,188,,199.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,211.5,90,,,percent of total billed charges,90% of total billed charges,82.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,161.45,68.7,,,percent of total billed charges,68.7% of total billed charges,188,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,136.3,58,,,percent of total billed charges,58% of total billed charges,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,199.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,47.87,211.5,
SPLINT DOYLE NASAL 1524055,7905951,CDM,270,RC,,,Outpatient,,,235,188,,199.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,211.5,90,,,percent of total billed charges,90% of total billed charges,82.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,161.45,68.7,,,percent of total billed charges,68.7% of total billed charges,188,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,136.3,58,,,percent of total billed charges,58% of total billed charges,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,199.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,47.87,211.5,
INTRODUCER SET 9 FR. 21-2340-24,7905966,CDM,270,RC,,,Outpatient,,,235,188,,199.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,211.5,90,,,percent of total billed charges,90% of total billed charges,82.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,161.45,68.7,,,percent of total billed charges,68.7% of total billed charges,188,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,136.3,58,,,percent of total billed charges,58% of total billed charges,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,199.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,47.87,211.5,
BIOPSY INSTRUMENT MAX CORE MC1416,7950243,CDM,272,RC,,,Outpatient,,,235,188,,199.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,211.5,90,,,percent of total billed charges,90% of total billed charges,82.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,161.45,68.7,,,percent of total billed charges,68.7% of total billed charges,188,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,136.3,58,,,percent of total billed charges,58% of total billed charges,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,199.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,47.87,211.5,
ELECTRODE LAPAROSCOPIC 0020,7950246,CDM,272,RC,,,Outpatient,,,235,188,,199.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,211.5,90,,,percent of total billed charges,90% of total billed charges,82.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,161.45,68.7,,,percent of total billed charges,68.7% of total billed charges,188,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,136.3,58,,,percent of total billed charges,58% of total billed charges,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,199.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,47.87,211.5,
BIOPSY INSTRUMENT MAX CORE MC1410,7950295,CDM,272,RC,,,Outpatient,,,235,188,,199.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,132.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,211.5,90,,,percent of total billed charges,90% of total billed charges,82.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,161.45,68.7,,,percent of total billed charges,68.7% of total billed charges,188,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,136.3,58,,,percent of total billed charges,58% of total billed charges,47.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,199.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,47.87,211.5,
IM INJECTION OR SUBCUTANEOUS,200013,CDM,761,RC,96372,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.8,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,50.12,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,59.34,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,48.89,216,
IM OR SUBQ INJECION (EACH),490772,CDM,720,RC,96372,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.8,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,50.12,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,59.34,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,48.89,216,
IM INJECTION INFLUENZA VACCINE,1000008,CDM,771,RC,G0008,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.65,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,37.26,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,56.44,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,216,
IM INJECTION PNEUMONCOCCAL VACCINE,1000009,CDM,771,RC,G0009,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.65,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,37.26,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,216,
IM INJECTION HEPATITIS B VACCINE,1000010,CDM,771,RC,G0010,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.65,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,37.26,100,,,fee schedule,Pays 100% Medicare OPPS,48.44,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,35.94,100,,,fee schedule,Pays 100% Medicare OPPS,32.35,216,
Immunization administration by a medical assistant or nurse,1090471,CDM,760,RC,90471,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.8,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,50.12,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,59.34,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,48.89,216,
IM OR SUBQ INJECTION (EACH),1090772,CDM,760,RC,96372,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.8,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,50.12,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,59.34,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,48.89,216,
SUTURE 0 VICRYL J906G,1570515,CDM,272,RC,,,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,204,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,48.89,216,
OUTPT IM INJ ANTIBIOTIC,2000007,CDM,769,RC,96372,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.8,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,50.12,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,59.34,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,48.89,216,
Immunization administration by a medical assistant or nurse,2000010,CDM,769,RC,90471,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.8,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,50.12,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,59.34,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,48.89,216,
IM INJECTION OR SUBCUTANEOUS,2000013,CDM,761,RC,96372,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.8,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,50.12,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,59.34,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,48.89,216,
IM INJECTION IMMUNE GLOBULIN,2090281,CDM,450,RC,90281,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,204,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,48.89,216,
IM INJECTION VACCINE,2090471,CDM,450,RC,96372,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.8,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,50.12,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,59.34,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,48.89,216,
IM INJECTION ANTIBIOTIC,2090772,CDM,450,RC,96372,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.8,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,50.12,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,59.34,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,48.89,216,
IM INJECTION OR SUBCUTANEOUS,2090773,CDM,450,RC,96372,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.8,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,50.12,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,59.34,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,48.89,216,
SILVER SULFADIAZINE 1% CREAM 400GM,2600094,CDM,637,RC,,,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,204,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,48.89,216,
SPIRIVA HANDIHALER 18MCG (5 COUNT),2600120,CDM,637,RC,,,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,204,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,48.89,216,
.BABESIOSIS IgG ANTIBODIES,3000026,CDM,300,RC,86753,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.1,130,,,fee schedule,Pays 130% Medicare OPPS,18.77,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.63,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,19.52,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,11.15,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,18.77,120.37,,,fee schedule,120.37% of custom fee schedule,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.1,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,11.15,216,
.BABESIOSIS IgM ANTIBODIES,3000028,CDM,300,RC,86753,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.1,130,,,fee schedule,Pays 130% Medicare OPPS,18.77,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.63,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,19.52,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,11.15,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,18.77,120.37,,,fee schedule,120.37% of custom fee schedule,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.1,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,11.15,216,
Blood test to determine the concentration of lead in the blood,3000186,CDM,301,RC,83655,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,12.11,100,,,fee schedule,Pays 100% Medicare OPPS,12.11,100,,,fee schedule,Pays 100% Medicare OPPS,12.11,100,,,fee schedule,Pays 100% Medicare OPPS,15.74,130,,,fee schedule,Pays 130% Medicare OPPS,12.04,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.35,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,12.52,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,12.11,100,,,fee schedule,Pays 100% Medicare OPPS,10.89,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,12.04,120.37,,,fee schedule,120.37% of custom fee schedule,12.11,100,,,fee schedule,Pays 100% Medicare OPPS,15.74,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,12.11,100,,,fee schedule,Pays 100% Medicare OPPS,10.89,216,
MYCOPLASMA PNEUMONIAE/IgM,3000219,CDM,302,RC,86738,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,13.24,100,,,fee schedule,Pays 100% Medicare OPPS,13.24,100,,,fee schedule,Pays 100% Medicare OPPS,13.24,100,,,fee schedule,Pays 100% Medicare OPPS,17.21,130,,,fee schedule,Pays 130% Medicare OPPS,20.05,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.5,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,20.85,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,13.24,100,,,fee schedule,Pays 100% Medicare OPPS,11.91,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,20.05,120.37,,,fee schedule,120.37% of custom fee schedule,13.24,100,,,fee schedule,Pays 100% Medicare OPPS,17.21,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,13.24,100,,,fee schedule,Pays 100% Medicare OPPS,11.91,216,
.TRIPLE TEST (ESTRIOL),3000314,CDM,301,RC,82677,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,24.18,100,,,fee schedule,Pays 100% Medicare OPPS,24.18,100,,,fee schedule,Pays 100% Medicare OPPS,24.18,100,,,fee schedule,Pays 100% Medicare OPPS,31.43,130,,,fee schedule,Pays 130% Medicare OPPS,36.6,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,24.66,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,38.07,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,24.18,100,,,fee schedule,Pays 100% Medicare OPPS,21.76,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,36.6,120.37,,,fee schedule,120.37% of custom fee schedule,24.18,100,,,fee schedule,Pays 100% Medicare OPPS,31.43,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,24.18,100,,,fee schedule,Pays 100% Medicare OPPS,21.76,216,
.TSI (THYROID STIM IMMUNOG,3000318,CDM,301,RC,84445,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,50.86,100,,,fee schedule,Pays 100% Medicare OPPS,50.86,100,,,fee schedule,Pays 100% Medicare OPPS,50.86,100,,,fee schedule,Pays 100% Medicare OPPS,66.11,130,,,fee schedule,Pays 130% Medicare OPPS,12.82,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,51.87,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,13.33,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,50.86,100,,,fee schedule,Pays 100% Medicare OPPS,45.77,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,12.82,120.37,,,fee schedule,120.37% of custom fee schedule,50.86,100,,,fee schedule,Pays 100% Medicare OPPS,66.11,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,50.86,100,,,fee schedule,Pays 100% Medicare OPPS,12.82,216,
INSULIN 3 SPECIMENS,3000383,CDM,301,RC,83525,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,14.85,130,,,fee schedule,Pays 130% Medicare OPPS,17.31,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.65,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,18,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,10.28,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,17.31,120.37,,,fee schedule,120.37% of custom fee schedule,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,14.85,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,10.28,216,
INSULIN 4 SPECIMENS,3000384,CDM,301,RC,83525,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,14.85,130,,,fee schedule,Pays 130% Medicare OPPS,17.31,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.65,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,18,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,10.28,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,17.31,120.37,,,fee schedule,120.37% of custom fee schedule,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,14.85,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,10.28,216,
INSULIN 5 SPECIMENS,3000385,CDM,301,RC,83525,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,14.85,130,,,fee schedule,Pays 130% Medicare OPPS,17.31,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.65,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,18,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,10.28,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,17.31,120.37,,,fee schedule,120.37% of custom fee schedule,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,14.85,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,10.28,216,
INSULIN 2 SPECIMENS,3000386,CDM,301,RC,83525,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,14.85,130,,,fee schedule,Pays 130% Medicare OPPS,17.31,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.65,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,18,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,10.28,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,17.31,120.37,,,fee schedule,120.37% of custom fee schedule,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,14.85,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,10.28,216,
ALDOLASE,3082085,CDM,301,RC,82085,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,9.71,100,,,fee schedule,Pays 100% Medicare OPPS,9.71,100,,,fee schedule,Pays 100% Medicare OPPS,9.71,100,,,fee schedule,Pays 100% Medicare OPPS,12.62,130,,,fee schedule,Pays 130% Medicare OPPS,14.69,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.9,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,15.27,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,9.71,100,,,fee schedule,Pays 100% Medicare OPPS,8.73,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,14.69,120.37,,,fee schedule,120.37% of custom fee schedule,9.71,100,,,fee schedule,Pays 100% Medicare OPPS,12.62,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,9.71,100,,,fee schedule,Pays 100% Medicare OPPS,8.73,216,
ALUMINUM LEVEL,3082108,CDM,301,RC,82108,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,25.48,100,,,fee schedule,Pays 100% Medicare OPPS,25.48,100,,,fee schedule,Pays 100% Medicare OPPS,25.48,100,,,fee schedule,Pays 100% Medicare OPPS,33.12,130,,,fee schedule,Pays 130% Medicare OPPS,25.52,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.98,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,26.54,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,25.48,100,,,fee schedule,Pays 100% Medicare OPPS,22.93,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,25.52,120.37,,,fee schedule,120.37% of custom fee schedule,25.48,100,,,fee schedule,Pays 100% Medicare OPPS,33.12,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,25.48,100,,,fee schedule,Pays 100% Medicare OPPS,22.93,216,
CARBOXYHEMOGLOBIN LEVEL,3082375,CDM,301,RC,82375,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,12.32,100,,,fee schedule,Pays 100% Medicare OPPS,12.32,100,,,fee schedule,Pays 100% Medicare OPPS,12.32,100,,,fee schedule,Pays 100% Medicare OPPS,16.01,130,,,fee schedule,Pays 130% Medicare OPPS,4.36,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.56,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,4.53,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,12.32,100,,,fee schedule,Pays 100% Medicare OPPS,11.08,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,4.36,120.37,,,fee schedule,120.37% of custom fee schedule,12.32,100,,,fee schedule,Pays 100% Medicare OPPS,16.01,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,12.32,100,,,fee schedule,Pays 100% Medicare OPPS,4.36,216,
CERULOPLASMIN,3082390,CDM,301,RC,82390,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,13.96,130,,,fee schedule,Pays 130% Medicare OPPS,16.26,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,10.95,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,16.91,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,9.66,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,16.26,120.37,,,fee schedule,120.37% of custom fee schedule,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,13.96,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,9.66,216,
INSULIN LEVEL,3083525,CDM,301,RC,83525,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,14.85,130,,,fee schedule,Pays 130% Medicare OPPS,17.31,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.65,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,18,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,10.28,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,17.31,120.37,,,fee schedule,120.37% of custom fee schedule,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,14.85,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,11.43,100,,,fee schedule,Pays 100% Medicare OPPS,10.28,216,
Blood test to determine the concentration of lead in the blood,3083655,CDM,301,RC,83655,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,12.11,100,,,fee schedule,Pays 100% Medicare OPPS,12.11,100,,,fee schedule,Pays 100% Medicare OPPS,12.11,100,,,fee schedule,Pays 100% Medicare OPPS,15.74,130,,,fee schedule,Pays 130% Medicare OPPS,12.04,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.35,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,12.52,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,12.11,100,,,fee schedule,Pays 100% Medicare OPPS,10.89,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,12.04,120.37,,,fee schedule,120.37% of custom fee schedule,12.11,100,,,fee schedule,Pays 100% Medicare OPPS,15.74,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,12.11,100,,,fee schedule,Pays 100% Medicare OPPS,10.89,216,
Blood test to evaluate thyroid function,3084480,CDM,301,RC,84480,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,14.18,100,,,fee schedule,Pays 100% Medicare OPPS,14.18,100,,,fee schedule,Pays 100% Medicare OPPS,14.18,100,,,fee schedule,Pays 100% Medicare OPPS,18.43,130,,,fee schedule,Pays 130% Medicare OPPS,19.3,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.46,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,20.07,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,14.18,100,,,fee schedule,Pays 100% Medicare OPPS,12.76,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,19.3,120.37,,,fee schedule,120.37% of custom fee schedule,14.18,100,,,fee schedule,Pays 100% Medicare OPPS,18.43,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,14.18,100,,,fee schedule,Pays 100% Medicare OPPS,12.76,216,
FIBRIN DEGRADATION PRODUC,3085378,CDM,305,RC,85362,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,6.89,100,,,fee schedule,Pays 100% Medicare OPPS,6.89,100,,,fee schedule,Pays 100% Medicare OPPS,6.89,100,,,fee schedule,Pays 100% Medicare OPPS,8.95,130,,,fee schedule,Pays 130% Medicare OPPS,10.42,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,7.02,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,10.84,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,6.89,100,,,fee schedule,Pays 100% Medicare OPPS,6.2,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,10.42,120.37,,,fee schedule,120.37% of custom fee schedule,6.89,100,,,fee schedule,Pays 100% Medicare OPPS,8.95,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,6.89,100,,,fee schedule,Pays 100% Medicare OPPS,6.2,216,
Blood test to monitor for cancer in the ovaries or testis,3086336,CDM,302,RC,86336,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,15.59,100,,,fee schedule,Pays 100% Medicare OPPS,15.59,100,,,fee schedule,Pays 100% Medicare OPPS,15.59,100,,,fee schedule,Pays 100% Medicare OPPS,20.26,130,,,fee schedule,Pays 130% Medicare OPPS,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.9,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,20.38,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,15.59,100,,,fee schedule,Pays 100% Medicare OPPS,14.03,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,15.59,100,,,fee schedule,Pays 100% Medicare OPPS,20.26,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,15.59,100,,,fee schedule,Pays 100% Medicare OPPS,14.03,216,
Blood test indicating infection with Hepatitis B,3086704,CDM,302,RC,86704,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,,,fee schedule,Pays 130% Medicare OPPS,18.25,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.29,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,18.98,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,10.84,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,18.25,120.37,,,fee schedule,120.37% of custom fee schedule,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,10.84,216,
HEP B SURFACE ANTIBODY,3086706,CDM,302,RC,86706,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,13.96,130,,,fee schedule,Pays 130% Medicare OPPS,16.26,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,10.95,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,16.91,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,9.66,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,16.26,120.37,,,fee schedule,120.37% of custom fee schedule,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,13.96,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,9.66,216,
HEPATITIS BE ANTIBODY,3086707,CDM,302,RC,86707,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,11.57,100,,,fee schedule,Pays 100% Medicare OPPS,11.57,100,,,fee schedule,Pays 100% Medicare OPPS,11.57,100,,,fee schedule,Pays 100% Medicare OPPS,15.04,130,,,fee schedule,Pays 130% Medicare OPPS,17.5,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.8,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,18.2,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,11.57,100,,,fee schedule,Pays 100% Medicare OPPS,10.41,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,17.5,120.37,,,fee schedule,120.37% of custom fee schedule,11.57,100,,,fee schedule,Pays 100% Medicare OPPS,15.04,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,11.57,100,,,fee schedule,Pays 100% Medicare OPPS,10.41,216,
MYCOPLASMA PNEUMONIAE/IgG,3086738,CDM,302,RC,86738,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,13.24,100,,,fee schedule,Pays 100% Medicare OPPS,13.24,100,,,fee schedule,Pays 100% Medicare OPPS,13.24,100,,,fee schedule,Pays 100% Medicare OPPS,17.21,130,,,fee schedule,Pays 130% Medicare OPPS,20.05,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.5,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,20.85,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,13.24,100,,,fee schedule,Pays 100% Medicare OPPS,11.91,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,20.05,120.37,,,fee schedule,120.37% of custom fee schedule,13.24,100,,,fee schedule,Pays 100% Medicare OPPS,17.21,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,13.24,100,,,fee schedule,Pays 100% Medicare OPPS,11.91,216,
PARVOVIRUS B19 IGG & IGM ABS,3086747,CDM,302,RC,86747,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,15.03,100,,,fee schedule,Pays 100% Medicare OPPS,15.03,100,,,fee schedule,Pays 100% Medicare OPPS,15.03,100,,,fee schedule,Pays 100% Medicare OPPS,19.53,130,,,fee schedule,Pays 130% Medicare OPPS,22.75,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.33,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,23.66,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,15.03,100,,,fee schedule,Pays 100% Medicare OPPS,13.52,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,22.75,120.37,,,fee schedule,120.37% of custom fee schedule,15.03,100,,,fee schedule,Pays 100% Medicare OPPS,19.53,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,15.03,100,,,fee schedule,Pays 100% Medicare OPPS,13.52,216,
.AFB CULTURE (AFB S&C),3087015,CDM,306,RC,87015,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,6.68,100,,,fee schedule,Pays 100% Medicare OPPS,6.68,100,,,fee schedule,Pays 100% Medicare OPPS,6.68,100,,,fee schedule,Pays 100% Medicare OPPS,8.68,130,,,fee schedule,Pays 130% Medicare OPPS,10.11,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.81,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,10.52,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,6.68,100,,,fee schedule,Pays 100% Medicare OPPS,6.01,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,10.11,120.37,,,fee schedule,120.37% of custom fee schedule,6.68,100,,,fee schedule,Pays 100% Medicare OPPS,8.68,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,6.68,100,,,fee schedule,Pays 100% Medicare OPPS,6.01,216,
CLOTEST,3087077,CDM,306,RC,87339,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,16,100,,,fee schedule,Pays 100% Medicare OPPS,16,100,,,fee schedule,Pays 100% Medicare OPPS,16,100,,,fee schedule,Pays 100% Medicare OPPS,20.8,130,,,fee schedule,Pays 130% Medicare OPPS,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.32,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,18.88,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,16,100,,,fee schedule,Pays 100% Medicare OPPS,14.4,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,16,100,,,fee schedule,Pays 100% Medicare OPPS,20.8,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,16,100,,,fee schedule,Pays 100% Medicare OPPS,14.4,216,
.CULTURE MYCOBACTERIA,3087116,CDM,306,RC,87116,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,10.8,100,,,fee schedule,Pays 100% Medicare OPPS,10.8,100,,,fee schedule,Pays 100% Medicare OPPS,10.8,100,,,fee schedule,Pays 100% Medicare OPPS,14.04,130,,,fee schedule,Pays 130% Medicare OPPS,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.01,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,10.8,100,,,fee schedule,Pays 100% Medicare OPPS,9.72,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,10.8,100,,,fee schedule,Pays 100% Medicare OPPS,14.04,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,10.8,100,,,fee schedule,Pays 100% Medicare OPPS,9.72,216,
HEP B SURFACE ANTIGEN,3087340,CDM,300,RC,87340,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,10.33,100,,,fee schedule,Pays 100% Medicare OPPS,10.33,100,,,fee schedule,Pays 100% Medicare OPPS,10.33,100,,,fee schedule,Pays 100% Medicare OPPS,13.42,130,,,fee schedule,Pays 130% Medicare OPPS,15.64,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,10.53,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,16.26,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,10.33,100,,,fee schedule,Pays 100% Medicare OPPS,9.29,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,15.64,120.37,,,fee schedule,120.37% of custom fee schedule,10.33,100,,,fee schedule,Pays 100% Medicare OPPS,13.42,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,10.33,100,,,fee schedule,Pays 100% Medicare OPPS,9.29,216,
HEPATITIS BE ANTIGEN,3087350,CDM,300,RC,87350,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,17.44,120.37,,,fee schedule,120.37% of custom fee schedule,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.76,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,18.14,125.18,,,fee schedule,125.18% of custom fee schedule,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,17.44,120.37,,,fee schedule,120.37% of custom fee schedule,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,216,
HYSTERO TRAY,4000804,CDM,270,RC,,,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,204,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,48.89,216,
HYSTERO CATH. SET 5FR,4000806,CDM,270,RC,,,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,60,100,,,fee schedule,Pays 100% Medicare OPPS,60,100,,,fee schedule,Pays 100% Medicare OPPS,60,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,216,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,204,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,48.89,216,
OB/GYN PROCEDURE TRAY,4000807,CDM,270,RC,,,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,60,100,,,fee schedule,Pays 100% Medicare OPPS,60,100,,,fee schedule,Pays 100% Medicare OPPS,60,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,216,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,204,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,48.89,216,
Immunization administration by a medical assistant or nurse,4090471,CDM,450,RC,90471,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.8,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,50.12,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,59.34,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,48.89,216,
IM OR SUBQ INJECTION (EACH),4090772,CDM,720,RC,96372,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.8,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,50.12,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,59.34,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,48.89,216,
"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",4376090,CDM,401,RC,77065,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,101.74,130,,,fee schedule,Pays 130% Medicare OPPS,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,134.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.2,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,71.65,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,78.26,100,,,fee schedule,Pays 100% Medicare OPPS,101.74,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,48.89,216,
"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",4376093,CDM,401,RC,77065,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,101.74,130,,,fee schedule,Pays 130% Medicare OPPS,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,134.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.2,102,,,fee schedule,Pays 102% Medicare OPPS,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,71.65,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,78.26,100,,,fee schedule,Pays 100% Medicare OPPS,101.74,130,,,fee schedule,Pays 130% Medicare OPPS,204,85,,,percent of total billed charges,85% of total billed charges,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,48.89,216,
NM I 123 CAPSULE 200 PER UCI,4500018,CDM,343,RC,A9516,HCPCS,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,60,100,,,fee schedule,Pays 100% Medicare OPPS,60,100,,,fee schedule,Pays 100% Medicare OPPS,60,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,216,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,204,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,48.89,216,
BONE SCREW HEX HEAD,7901060,CDM,278,RC,,,Both,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,60,100,,,fee schedule,Pays 100% Medicare OPPS,60,100,,,fee schedule,Pays 100% Medicare OPPS,60,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,216,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,204,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,48.89,216,
ENDOPATH GRASPERS 5DSG,7950142,CDM,272,RC,,,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,60,100,,,fee schedule,Pays 100% Medicare OPPS,60,100,,,fee schedule,Pays 100% Medicare OPPS,60,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,216,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,204,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,48.89,216,
ENDOPATH DISSECTOR 5DCD,7950145,CDM,272,RC,,,Outpatient,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,60,100,,,fee schedule,Pays 100% Medicare OPPS,60,100,,,fee schedule,Pays 100% Medicare OPPS,60,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,135.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,216,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,204,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,48.89,216,
HERNIA BARD MESH 6 X 6 0112720,7950302,CDM,278,RC,C1781,HCPCS,Both,,,240,192,,204,85,,,percent of total billed charges,85% of total billed charges,60,100,,,fee schedule,Pays 100% Medicare OPPS,60,100,,,fee schedule,Pays 100% Medicare OPPS,60,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,216,90,,,percent of total billed charges,90% of total billed charges,84,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,164.88,68.7,,,percent of total billed charges,68.7% of total billed charges,192,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,216,90,,,fee schedule,Pays 90% Medicare OPPS,139.2,58,,,percent of total billed charges,58% of total billed charges,48.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,204,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,48.89,216,
.....MRI GADOLYNIUM PER 15 ML,440026,CDM,255,RC,A9576,HCPCS,Outpatient,,,245,196,,208.25,85,,,percent of total billed charges,85% of total billed charges,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,220.5,90,,,percent of total billed charges,90% of total billed charges,85.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,168.32,68.7,,,percent of total billed charges,68.7% of total billed charges,196,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,220.5,90,,,fee schedule,Pays 90% Medicare OPPS,142.1,58,,,percent of total billed charges,58% of total billed charges,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,49.91,220.5,
NAIL DECOMPRESSION,2011740,CDM,450,RC,11740,HCPCS,Outpatient,,,245,196,,208.25,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,220.5,90,,,percent of total billed charges,90% of total billed charges,85.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,168.32,68.7,,,percent of total billed charges,68.7% of total billed charges,196,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,142.1,58,,,percent of total billed charges,58% of total billed charges,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,208.25,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,49.91,220.5,
STRAPPING ELBOW OR WRIST,2029260,CDM,450,RC,29260,HCPCS,Outpatient,,,245,196,,208.25,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,65.72,130,,,fee schedule,Pays 130% Medicare OPPS,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,51,102,,,fee schedule,Pays 102% Medicare OPPS,220.5,90,,,percent of total billed charges,90% of total billed charges,85.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,168.32,68.7,,,percent of total billed charges,68.7% of total billed charges,196,80,,,percent of total billed charges,80 percent of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,45,90,,,fee schedule,Pays 90% Medicare OPPS,142.1,58,,,percent of total billed charges,58% of total billed charges,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,50.55,100,,,fee schedule,Pays 100% Medicare OPPS,65.72,130,,,fee schedule,Pays 130% Medicare OPPS,208.25,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,45,220.5,
STRAPPING HAND OR FINGER,2029280,CDM,450,RC,,,Outpatient,,,245,196,,208.25,85,,,percent of total billed charges,85% of total billed charges,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,220.5,90,,,percent of total billed charges,90% of total billed charges,85.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,168.32,68.7,,,percent of total billed charges,68.7% of total billed charges,196,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,220.5,90,,,fee schedule,Pays 90% Medicare OPPS,142.1,58,,,percent of total billed charges,58% of total billed charges,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,208.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,49.91,220.5,
STRAPPING OF KNEE,2029530,CDM,450,RC,,,Outpatient,,,245,196,,208.25,85,,,percent of total billed charges,85% of total billed charges,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,220.5,90,,,percent of total billed charges,90% of total billed charges,85.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,168.32,68.7,,,percent of total billed charges,68.7% of total billed charges,196,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,220.5,90,,,fee schedule,Pays 90% Medicare OPPS,142.1,58,,,percent of total billed charges,58% of total billed charges,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,208.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,49.91,220.5,
STRAPPING OF TOES,2029550,CDM,450,RC,29550,HCPCS,Outpatient,,,245,196,,208.25,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,65.72,130,,,fee schedule,Pays 130% Medicare OPPS,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,51,102,,,fee schedule,Pays 102% Medicare OPPS,220.5,90,,,percent of total billed charges,90% of total billed charges,85.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,168.32,68.7,,,percent of total billed charges,68.7% of total billed charges,196,80,,,percent of total billed charges,80 percent of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,45,90,,,fee schedule,Pays 90% Medicare OPPS,142.1,58,,,percent of total billed charges,58% of total billed charges,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,50.55,100,,,fee schedule,Pays 100% Medicare OPPS,65.72,130,,,fee schedule,Pays 130% Medicare OPPS,208.25,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,45,220.5,
ULTANE (SEVOFLURANE) GAS,2600043,CDM,250,RC,,,Outpatient,,,245,196,,208.25,85,,,percent of total billed charges,85% of total billed charges,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,220.5,90,,,percent of total billed charges,90% of total billed charges,85.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,168.32,68.7,,,percent of total billed charges,68.7% of total billed charges,196,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,220.5,90,,,fee schedule,Pays 90% Medicare OPPS,142.1,58,,,percent of total billed charges,58% of total billed charges,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,208.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,49.91,220.5,
PROCALAMI (PROCALAMINE 3% +ELEC) IV:,2610043,CDM,250,RC,,,Outpatient,,,245,196,,208.25,85,,,percent of total billed charges,85% of total billed charges,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,220.5,90,,,percent of total billed charges,90% of total billed charges,85.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,168.32,68.7,,,percent of total billed charges,68.7% of total billed charges,196,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,220.5,90,,,fee schedule,Pays 90% Medicare OPPS,142.1,58,,,percent of total billed charges,58% of total billed charges,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,208.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,49.91,220.5,
#,3000134,CDM,301,RC,,,Outpatient,,,245,196,,208.25,85,,,percent of total billed charges,85% of total billed charges,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,220.5,90,,,percent of total billed charges,90% of total billed charges,85.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,168.32,68.7,,,percent of total billed charges,68.7% of total billed charges,196,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,220.5,90,,,fee schedule,Pays 90% Medicare OPPS,142.1,58,,,percent of total billed charges,58% of total billed charges,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,208.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,49.91,220.5,
RBC FOLATE,3000135,CDM,301,RC,82747,HCPCS,Outpatient,,,245,196,,208.25,85,,,percent of total billed charges,85% of total billed charges,17.64,100,,,fee schedule,Pays 100% Medicare OPPS,17.64,100,,,fee schedule,Pays 100% Medicare OPPS,17.64,100,,,fee schedule,Pays 100% Medicare OPPS,22.94,130,,,fee schedule,Pays 130% Medicare OPPS,26.22,120.37,,,fee schedule,120.37% of custom fee schedule,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18,102,,,fee schedule,Pays 102% Medicare OPPS,220.5,90,,,percent of total billed charges,90% of total billed charges,27.26,125.18,,,fee schedule,125.18% of custom fee schedule,168.32,68.7,,,percent of total billed charges,68.7% of total billed charges,196,80,,,percent of total billed charges,80 percent of total billed charges,17.64,100,,,fee schedule,Pays 100% Medicare OPPS,15.88,90,,,fee schedule,Pays 90% Medicare OPPS,142.1,58,,,percent of total billed charges,58% of total billed charges,26.22,120.37,,,fee schedule,120.37% of custom fee schedule,17.64,100,,,fee schedule,Pays 100% Medicare OPPS,22.94,130,,,fee schedule,Pays 130% Medicare OPPS,208.25,85,,,percent of total billed charges,85% of total billed charges,17.64,100,,,fee schedule,Pays 100% Medicare OPPS,15.88,220.5,
"TRYPTASE, SERUM",3000316,CDM,300,RC,83520,HCPCS,Outpatient,,,245,196,,208.25,85,,,percent of total billed charges,85% of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,130,,,fee schedule,Pays 130% Medicare OPPS,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.61,102,,,fee schedule,Pays 102% Medicare OPPS,220.5,90,,,percent of total billed charges,90% of total billed charges,20.38,125.18,,,fee schedule,125.18% of custom fee schedule,168.32,68.7,,,percent of total billed charges,68.7% of total billed charges,196,80,,,percent of total billed charges,80 percent of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,15.54,90,,,fee schedule,Pays 90% Medicare OPPS,142.1,58,,,percent of total billed charges,58% of total billed charges,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,130,,,fee schedule,Pays 130% Medicare OPPS,208.25,85,,,percent of total billed charges,85% of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,15.54,220.5,
Blood test to measure average blood glucose levels for past 2-3 months,3000690,CDM,301,RC,83036,HCPCS,Outpatient,,,245,196,,208.25,85,,,percent of total billed charges,85% of total billed charges,9.71,100,,,fee schedule,Pays 100% Medicare OPPS,9.71,100,,,fee schedule,Pays 100% Medicare OPPS,9.71,100,,,fee schedule,Pays 100% Medicare OPPS,12.62,130,,,fee schedule,Pays 130% Medicare OPPS,14.69,120.37,,,fee schedule,120.37% of custom fee schedule,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.9,102,,,fee schedule,Pays 102% Medicare OPPS,220.5,90,,,percent of total billed charges,90% of total billed charges,15.27,125.18,,,fee schedule,125.18% of custom fee schedule,168.32,68.7,,,percent of total billed charges,68.7% of total billed charges,196,80,,,percent of total billed charges,80 percent of total billed charges,9.71,100,,,fee schedule,Pays 100% Medicare OPPS,8.73,90,,,fee schedule,Pays 90% Medicare OPPS,142.1,58,,,percent of total billed charges,58% of total billed charges,14.69,120.37,,,fee schedule,120.37% of custom fee schedule,9.71,100,,,fee schedule,Pays 100% Medicare OPPS,12.62,130,,,fee schedule,Pays 130% Medicare OPPS,208.25,85,,,percent of total billed charges,85% of total billed charges,9.71,100,,,fee schedule,Pays 100% Medicare OPPS,8.73,220.5,
Blood test to measure average blood glucose levels for past 2-3 months,3000810,CDM,301,RC,83036,HCPCS,Outpatient,,,245,196,,208.25,85,,,percent of total billed charges,85% of total billed charges,9.71,100,,,fee schedule,Pays 100% Medicare OPPS,9.71,100,,,fee schedule,Pays 100% Medicare OPPS,9.71,100,,,fee schedule,Pays 100% Medicare OPPS,12.62,130,,,fee schedule,Pays 130% Medicare OPPS,14.69,120.37,,,fee schedule,120.37% of custom fee schedule,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.9,102,,,fee schedule,Pays 102% Medicare OPPS,220.5,90,,,percent of total billed charges,90% of total billed charges,15.27,125.18,,,fee schedule,125.18% of custom fee schedule,168.32,68.7,,,percent of total billed charges,68.7% of total billed charges,196,80,,,percent of total billed charges,80 percent of total billed charges,9.71,100,,,fee schedule,Pays 100% Medicare OPPS,8.73,90,,,fee schedule,Pays 90% Medicare OPPS,142.1,58,,,percent of total billed charges,58% of total billed charges,14.69,120.37,,,fee schedule,120.37% of custom fee schedule,9.71,100,,,fee schedule,Pays 100% Medicare OPPS,12.62,130,,,fee schedule,Pays 130% Medicare OPPS,208.25,85,,,percent of total billed charges,85% of total billed charges,9.71,100,,,fee schedule,Pays 100% Medicare OPPS,8.73,220.5,
ACE LEVEL,3082164,CDM,301,RC,82164,HCPCS,Outpatient,,,245,196,,208.25,85,,,percent of total billed charges,85% of total billed charges,14.6,100,,,fee schedule,Pays 100% Medicare OPPS,14.6,100,,,fee schedule,Pays 100% Medicare OPPS,14.6,100,,,fee schedule,Pays 100% Medicare OPPS,18.98,130,,,fee schedule,Pays 130% Medicare OPPS,22.09,120.37,,,fee schedule,120.37% of custom fee schedule,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.89,102,,,fee schedule,Pays 102% Medicare OPPS,220.5,90,,,percent of total billed charges,90% of total billed charges,22.97,125.18,,,fee schedule,125.18% of custom fee schedule,168.32,68.7,,,percent of total billed charges,68.7% of total billed charges,196,80,,,percent of total billed charges,80 percent of total billed charges,14.6,100,,,fee schedule,Pays 100% Medicare OPPS,13.14,90,,,fee schedule,Pays 90% Medicare OPPS,142.1,58,,,percent of total billed charges,58% of total billed charges,22.09,120.37,,,fee schedule,120.37% of custom fee schedule,14.6,100,,,fee schedule,Pays 100% Medicare OPPS,18.98,130,,,fee schedule,Pays 130% Medicare OPPS,208.25,85,,,percent of total billed charges,85% of total billed charges,14.6,100,,,fee schedule,Pays 100% Medicare OPPS,13.14,220.5,
Blood test to measure average blood glucose levels for past 2-3 months,3083036,CDM,301,RC,83036,HCPCS,Outpatient,,,245,196,,208.25,85,,,percent of total billed charges,85% of total billed charges,9.71,100,,,fee schedule,Pays 100% Medicare OPPS,9.71,100,,,fee schedule,Pays 100% Medicare OPPS,9.71,100,,,fee schedule,Pays 100% Medicare OPPS,12.62,130,,,fee schedule,Pays 130% Medicare OPPS,14.69,120.37,,,fee schedule,120.37% of custom fee schedule,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.9,102,,,fee schedule,Pays 102% Medicare OPPS,220.5,90,,,percent of total billed charges,90% of total billed charges,15.27,125.18,,,fee schedule,125.18% of custom fee schedule,168.32,68.7,,,percent of total billed charges,68.7% of total billed charges,196,80,,,percent of total billed charges,80 percent of total billed charges,9.71,100,,,fee schedule,Pays 100% Medicare OPPS,8.73,90,,,fee schedule,Pays 90% Medicare OPPS,142.1,58,,,percent of total billed charges,58% of total billed charges,14.69,120.37,,,fee schedule,120.37% of custom fee schedule,9.71,100,,,fee schedule,Pays 100% Medicare OPPS,12.62,130,,,fee schedule,Pays 130% Medicare OPPS,208.25,85,,,percent of total billed charges,85% of total billed charges,9.71,100,,,fee schedule,Pays 100% Medicare OPPS,8.73,220.5,
FREE T3,3084481,CDM,301,RC,84481,HCPCS,Outpatient,,,245,196,,208.25,85,,,percent of total billed charges,85% of total billed charges,16.94,100,,,fee schedule,Pays 100% Medicare OPPS,16.94,100,,,fee schedule,Pays 100% Medicare OPPS,16.94,100,,,fee schedule,Pays 100% Medicare OPPS,22.02,130,,,fee schedule,Pays 130% Medicare OPPS,25.64,120.37,,,fee schedule,120.37% of custom fee schedule,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.27,102,,,fee schedule,Pays 102% Medicare OPPS,220.5,90,,,percent of total billed charges,90% of total billed charges,26.66,125.18,,,fee schedule,125.18% of custom fee schedule,168.32,68.7,,,percent of total billed charges,68.7% of total billed charges,196,80,,,percent of total billed charges,80 percent of total billed charges,16.94,100,,,fee schedule,Pays 100% Medicare OPPS,15.24,90,,,fee schedule,Pays 90% Medicare OPPS,142.1,58,,,percent of total billed charges,58% of total billed charges,25.64,120.37,,,fee schedule,120.37% of custom fee schedule,16.94,100,,,fee schedule,Pays 100% Medicare OPPS,22.02,130,,,fee schedule,Pays 130% Medicare OPPS,208.25,85,,,percent of total billed charges,85% of total billed charges,16.94,100,,,fee schedule,Pays 100% Medicare OPPS,15.24,220.5,
3RD VON WILLENBRAND ANTIGEN,3085246,CDM,301,RC,85246,HCPCS,Outpatient,,,245,196,,208.25,85,,,percent of total billed charges,85% of total billed charges,22.94,100,,,fee schedule,Pays 100% Medicare OPPS,22.94,100,,,fee schedule,Pays 100% Medicare OPPS,22.94,100,,,fee schedule,Pays 100% Medicare OPPS,29.82,130,,,fee schedule,Pays 130% Medicare OPPS,34.73,120.37,,,fee schedule,120.37% of custom fee schedule,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,23.39,102,,,fee schedule,Pays 102% Medicare OPPS,220.5,90,,,percent of total billed charges,90% of total billed charges,36.11,125.18,,,fee schedule,125.18% of custom fee schedule,168.32,68.7,,,percent of total billed charges,68.7% of total billed charges,196,80,,,percent of total billed charges,80 percent of total billed charges,22.94,100,,,fee schedule,Pays 100% Medicare OPPS,20.64,90,,,fee schedule,Pays 90% Medicare OPPS,142.1,58,,,percent of total billed charges,58% of total billed charges,34.73,120.37,,,fee schedule,120.37% of custom fee schedule,22.94,100,,,fee schedule,Pays 100% Medicare OPPS,29.82,130,,,fee schedule,Pays 130% Medicare OPPS,208.25,85,,,percent of total billed charges,85% of total billed charges,22.94,100,,,fee schedule,Pays 100% Medicare OPPS,20.64,220.5,
"..PHLEBOTOMY, THERAPEUTIC",3099195,CDM,940,RC,99195,HCPCS,Outpatient,,,245,196,,208.25,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,220.5,90,,,percent of total billed charges,90% of total billed charges,85.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,168.32,68.7,,,percent of total billed charges,68.7% of total billed charges,196,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,142.1,58,,,percent of total billed charges,58% of total billed charges,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,49.91,220.5,
GLOVE COMPRESSION,5007118,CDM,270,RC,,,Outpatient,,,245,196,,208.25,85,,,percent of total billed charges,85% of total billed charges,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,220.5,90,,,percent of total billed charges,90% of total billed charges,85.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,168.32,68.7,,,percent of total billed charges,68.7% of total billed charges,196,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,220.5,90,,,fee schedule,Pays 90% Medicare OPPS,142.1,58,,,percent of total billed charges,58% of total billed charges,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,208.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,49.91,220.5,
CATH ERCP ERCP-1-BT,7905790,CDM,272,RC,,,Outpatient,,,245,196,,208.25,85,,,percent of total billed charges,85% of total billed charges,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,220.5,90,,,percent of total billed charges,90% of total billed charges,85.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,168.32,68.7,,,percent of total billed charges,68.7% of total billed charges,196,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,220.5,90,,,fee schedule,Pays 90% Medicare OPPS,142.1,58,,,percent of total billed charges,58% of total billed charges,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,208.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,49.91,220.5,
ENDOPATH SCISSORS 5DCS,7950150,CDM,272,RC,,,Outpatient,,,245,196,,208.25,85,,,percent of total billed charges,85% of total billed charges,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,220.5,90,,,percent of total billed charges,90% of total billed charges,85.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,168.32,68.7,,,percent of total billed charges,68.7% of total billed charges,196,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,220.5,90,,,fee schedule,Pays 90% Medicare OPPS,142.1,58,,,percent of total billed charges,58% of total billed charges,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,208.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,49.91,220.5,
STAPLER CONTOUR CUTTER RELOAD CR40B,7950282,CDM,272,RC,,,Outpatient,,,245,196,,208.25,85,,,percent of total billed charges,85% of total billed charges,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,220.5,90,,,percent of total billed charges,90% of total billed charges,85.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,168.32,68.7,,,percent of total billed charges,68.7% of total billed charges,196,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,220.5,90,,,fee schedule,Pays 90% Medicare OPPS,142.1,58,,,percent of total billed charges,58% of total billed charges,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,208.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,49.91,220.5,
STAPLER CONTOUR CUTTER RELOAD CR40G,7950283,CDM,272,RC,,,Outpatient,,,245,196,,208.25,85,,,percent of total billed charges,85% of total billed charges,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,61.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,138.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,220.5,90,,,percent of total billed charges,90% of total billed charges,85.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,168.32,68.7,,,percent of total billed charges,68.7% of total billed charges,196,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,220.5,90,,,fee schedule,Pays 90% Medicare OPPS,142.1,58,,,percent of total billed charges,58% of total billed charges,49.91,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,208.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,49.91,220.5,
COVID-19 SWAB,300800,CDM,300,RC,87635,HCPCS,Outpatient,,,250,200,,212.5,85,,,percent of total billed charges,85% of total billed charges,51.31,100,,,fee schedule,Pays 100% Medicare OPPS,51.31,100,,,fee schedule,Pays 100% Medicare OPPS,51.31,100,,,fee schedule,Pays 100% Medicare OPPS,66.7,130,,,fee schedule,Pays 130% Medicare OPPS,61.76,120.37,,,fee schedule,120.37% of custom fee schedule,141.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,141.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,141.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,141.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,52.33,102,,,fee schedule,Pays 102% Medicare OPPS,225,90,,,percent of total billed charges,90% of total billed charges,64.23,125.18,,,fee schedule,125.18% of custom fee schedule,171.75,68.7,,,percent of total billed charges,68.7% of total billed charges,200,80,,,percent of total billed charges,80 percent of total billed charges,51.31,100,,,fee schedule,Pays 100% Medicare OPPS,46.17,90,,,fee schedule,Pays 90% Medicare OPPS,145,58,,,percent of total billed charges,58% of total billed charges,61.76,120.37,,,fee schedule,120.37% of custom fee schedule,51.31,100,,,fee schedule,Pays 100% Medicare OPPS,66.7,130,,,fee schedule,Pays 130% Medicare OPPS,212.5,85,,,percent of total billed charges,85% of total billed charges,51.31,100,,,fee schedule,Pays 100% Medicare OPPS,46.17,225,
REMOVE SKIN TAGS,1011201,CDM,490,RC,11201,HCPCS,Outpatient,,,250,200,,212.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,50.93,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,,,,,other,Not reimbursable per contract,225,90,,,percent of total billed charges,90% of total billed charges,87.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,171.75,68.7,,,percent of total billed charges,68.7% of total billed charges,200,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,145,58,,,percent of total billed charges,58% of total billed charges,50.93,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,212.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,50.93,986.63,
VISION BLUE (TRYPAN) OPHTH 0.06% 0.5ML,2660015,CDM,250,RC,,,Outpatient,,,250,200,,212.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,50.93,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,141.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,141.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,141.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,141.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,225,90,,,percent of total billed charges,90% of total billed charges,87.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,171.75,68.7,,,percent of total billed charges,68.7% of total billed charges,200,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,145,58,,,percent of total billed charges,58% of total billed charges,50.93,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,212.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,50.93,225,
CoV-2 SARS ANTIGEN SWAB,3087426,CDM,300,RC,87426,HCPCS,Outpatient,,,250,200,,212.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,45.92,130,,,fee schedule,Pays 130% Medicare OPPS,43.55,120.37,,,fee schedule,120.37% of custom fee schedule,141.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,141.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,141.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,141.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,225,90,,,percent of total billed charges,90% of total billed charges,45.29,125.18,,,fee schedule,125.18% of custom fee schedule,171.75,68.7,,,percent of total billed charges,68.7% of total billed charges,200,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,145,58,,,percent of total billed charges,58% of total billed charges,43.55,120.37,,,fee schedule,120.37% of custom fee schedule,35.33,100,,,fee schedule,Pays 100% Medicare OPPS,45.92,130,,,fee schedule,Pays 130% Medicare OPPS,212.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,35.33,225,
BOOT COMFY FLEECE W/O AMBULATION,7905923,CDM,270,RC,L4396,HCPCS,Outpatient,,,250,200,,212.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,50.93,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,141.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,141.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,141.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,141.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,225,90,,,percent of total billed charges,90% of total billed charges,87.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,171.75,68.7,,,percent of total billed charges,68.7% of total billed charges,200,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,145,58,,,percent of total billed charges,58% of total billed charges,50.93,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,212.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,50.93,225,
LIGACLIP CLIP APPLIER MCM30,7950139,CDM,272,RC,,,Outpatient,,,250,200,,212.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,50.93,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,141.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,141.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,141.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,141.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,225,90,,,percent of total billed charges,90% of total billed charges,87.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,171.75,68.7,,,percent of total billed charges,68.7% of total billed charges,200,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,145,58,,,percent of total billed charges,58% of total billed charges,50.93,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,212.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,50.93,225,
**DO NOT USE**,7905237,CDM,272,RC,,,Outpatient,,,255,204,,216.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,144.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,144.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,144.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,144.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,229.5,90,,,percent of total billed charges,90% of total billed charges,89.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,175.19,68.7,,,percent of total billed charges,68.7% of total billed charges,204,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,147.9,58,,,percent of total billed charges,58% of total billed charges,51.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,216.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,51.94,229.5,
SURGICEL 2 X 3,7905529,CDM,272,RC,,,Outpatient,,,255,204,,216.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,51.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,144.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,144.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,144.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,144.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,229.5,90,,,percent of total billed charges,90% of total billed charges,89.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,175.19,68.7,,,percent of total billed charges,68.7% of total billed charges,204,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,147.9,58,,,percent of total billed charges,58% of total billed charges,51.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,216.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,51.94,229.5,
ORTHO BASIC HAND TRAY,7901200,CDM,272,RC,,,Outpatient,,,256,204.8,,217.6,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,52.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,144.64,56.5,,,percent of total billed charges,56.5 percent of total billed charges,144.64,56.5,,,percent of total billed charges,56.5 percent of total billed charges,144.64,56.5,,,percent of total billed charges,56.5 percent of total billed charges,144.64,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,230.4,90,,,percent of total billed charges,90% of total billed charges,89.6,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,175.87,68.7,,,percent of total billed charges,68.7% of total billed charges,204.8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,148.48,58,,,percent of total billed charges,58% of total billed charges,52.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,217.6,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,52.15,230.4,
KNEE ORTHOSIS WRAP AROUND FRDM XXXL,7905287,CDM,270,RC,,,Outpatient,,,256.5,205.2,,218.03,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,52.25,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,144.92,56.5,,,percent of total billed charges,56.5 percent of total billed charges,144.92,56.5,,,percent of total billed charges,56.5 percent of total billed charges,144.92,56.5,,,percent of total billed charges,56.5 percent of total billed charges,144.92,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,230.85,90,,,percent of total billed charges,90% of total billed charges,89.78,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,176.22,68.7,,,percent of total billed charges,68.7% of total billed charges,205.2,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,148.77,58,,,percent of total billed charges,58% of total billed charges,52.25,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,218.03,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,52.25,230.85,
"New patient office or other outpatient visit, typically 10 minutes",2000009,CDM,510,RC,99202,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,234,90,,,percent of total billed charges,90% of total billed charges,91,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,150.8,58,,,percent of total billed charges,58% of total billed charges,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,221,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,52.96,234,
EAR IRRIGATION,2069210,CDM,450,RC,,,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,234,90,,,percent of total billed charges,90% of total billed charges,91,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,150.8,58,,,percent of total billed charges,58% of total billed charges,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,221,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,52.96,234,
ROCEPHIN INJ (CEFTRIAXONE NA) 500MG,2601061,CDM,636,RC,J0696,HCPCS,Both,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,0.6,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,234,90,,,percent of total billed charges,90% of total billed charges,0.63,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,150.8,58,,,percent of total billed charges,58% of total billed charges,0.6,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,221,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.6,234,
INFED (IRON DEXTRAN) INJ 50MG/ML VIAL,2601325,CDM,636,RC,J1750,HCPCS,Both,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,16.53,100,,,fee schedule,Pays 100% Medicare OPPS,16.53,100,,,fee schedule,Pays 100% Medicare OPPS,16.53,100,,,fee schedule,Pays 100% Medicare OPPS,22.63,130,,,fee schedule,Pays 130% Medicare OPPS,19.9,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,16.86,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,20.69,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,16.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.87,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,19.9,120.37,,,fee schedule,120.37% of custom fee schedule,17.41,100,,,fee schedule,Pays 100% Medicare OPPS,22.63,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,16.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.87,234,
NF-CEDAX (CEFTIBUTEN) 90MG/5ML SUSP,2603060,CDM,637,RC,,,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,234,90,,,percent of total billed charges,90% of total billed charges,91,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,150.8,58,,,percent of total billed charges,58% of total billed charges,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,221,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,52.96,234,
BIAXIN (CLARITHROMYCIN)250MG/5ML SP:50ML,2603067,CDM,637,RC,,,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,234,90,,,percent of total billed charges,90% of total billed charges,91,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,150.8,58,,,percent of total billed charges,58% of total billed charges,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,221,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,52.96,234,
3RD ANTIMITOCHONDRIAL ANTIBOD,3000020,CDM,302,RC,86255,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,,,fee schedule,Pays 130% Medicare OPPS,18.25,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.29,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,18.98,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,10.84,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,18.25,120.37,,,fee schedule,120.37% of custom fee schedule,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,10.84,234,
"BENZODIAZEPINE, UA",3000029,CDM,301,RC,80346,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,28,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,234,90,,,percent of total billed charges,90% of total billed charges,29.12,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,150.8,58,,,percent of total billed charges,58% of total billed charges,28,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,221,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,28,234,
FLECAINIDE LEVEL,3000112,CDM,301,RC,80299,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.01,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,18.95,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,234,
Blood test to if peptic ulcers are caused by a certain bacterium,3000139,CDM,302,RC,86677,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,16.85,100,,,fee schedule,Pays 100% Medicare OPPS,16.85,100,,,fee schedule,Pays 100% Medicare OPPS,16.85,100,,,fee schedule,Pays 100% Medicare OPPS,21.9,130,,,fee schedule,Pays 130% Medicare OPPS,21.97,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.18,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,22.85,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,16.85,100,,,fee schedule,Pays 100% Medicare OPPS,15.16,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,21.97,120.37,,,fee schedule,120.37% of custom fee schedule,16.85,100,,,fee schedule,Pays 100% Medicare OPPS,21.9,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,16.85,100,,,fee schedule,Pays 100% Medicare OPPS,15.16,234,
Blood test to determine autoimmune disorders,3000185,CDM,302,RC,86039,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,11.16,100,,,fee schedule,Pays 100% Medicare OPPS,11.16,100,,,fee schedule,Pays 100% Medicare OPPS,11.16,100,,,fee schedule,Pays 100% Medicare OPPS,14.5,130,,,fee schedule,Pays 130% Medicare OPPS,16.9,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.38,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,17.58,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,11.16,100,,,fee schedule,Pays 100% Medicare OPPS,10.04,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,16.9,120.37,,,fee schedule,120.37% of custom fee schedule,11.16,100,,,fee schedule,Pays 100% Medicare OPPS,14.5,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,11.16,100,,,fee schedule,Pays 100% Medicare OPPS,10.04,234,
MUCOPOLYSACCHARIDES URINE QUANT,3000216,CDM,301,RC,83864,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,28.5,100,,,fee schedule,Pays 100% Medicare OPPS,28.5,100,,,fee schedule,Pays 100% Medicare OPPS,28.5,100,,,fee schedule,Pays 100% Medicare OPPS,37.05,130,,,fee schedule,Pays 130% Medicare OPPS,16.26,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,29.07,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,16.91,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,28.5,100,,,fee schedule,Pays 100% Medicare OPPS,25.65,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,16.26,120.37,,,fee schedule,120.37% of custom fee schedule,28.5,100,,,fee schedule,Pays 100% Medicare OPPS,37.05,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,28.5,100,,,fee schedule,Pays 100% Medicare OPPS,16.26,234,
Blood test to determine if antibodies exist for measles,3000274,CDM,302,RC,86765,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.13,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,20.28,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,234,
Blood test to determine if antibodies exist for measles,3000275,CDM,302,RC,86765,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.13,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,20.28,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,234,
.SS-A ANTIBODY (SJOGREN),3000288,CDM,302,RC,86235,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.28,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,28.23,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,234,
.SS-B ANTIBODY (SJOGREN),3000289,CDM,302,RC,86235,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.28,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,28.23,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,234,
THYROID MICROSOMAL AB,3000302,CDM,302,RC,86376,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,14.55,100,,,fee schedule,Pays 100% Medicare OPPS,14.55,100,,,fee schedule,Pays 100% Medicare OPPS,14.55,100,,,fee schedule,Pays 100% Medicare OPPS,18.91,130,,,fee schedule,Pays 130% Medicare OPPS,22.03,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.84,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,22.91,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,14.55,100,,,fee schedule,Pays 100% Medicare OPPS,13.09,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,22.03,120.37,,,fee schedule,120.37% of custom fee schedule,14.55,100,,,fee schedule,Pays 100% Medicare OPPS,18.91,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,14.55,100,,,fee schedule,Pays 100% Medicare OPPS,13.09,234,
THYROID PEROXIDASE AB,3000303,CDM,302,RC,86376,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,14.55,100,,,fee schedule,Pays 100% Medicare OPPS,14.55,100,,,fee schedule,Pays 100% Medicare OPPS,14.55,100,,,fee schedule,Pays 100% Medicare OPPS,18.91,130,,,fee schedule,Pays 130% Medicare OPPS,22.03,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.84,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,22.91,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,14.55,100,,,fee schedule,Pays 100% Medicare OPPS,13.09,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,22.03,120.37,,,fee schedule,120.37% of custom fee schedule,14.55,100,,,fee schedule,Pays 100% Medicare OPPS,18.91,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,14.55,100,,,fee schedule,Pays 100% Medicare OPPS,13.09,234,
PHENYLALANINE PLASMA,3000639,CDM,301,RC,84030,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,5.5,100,,,fee schedule,Pays 100% Medicare OPPS,5.5,100,,,fee schedule,Pays 100% Medicare OPPS,5.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.15,130,,,fee schedule,Pays 130% Medicare OPPS,8.33,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.61,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,8.66,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,5.5,100,,,fee schedule,Pays 100% Medicare OPPS,4.95,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,8.33,120.37,,,fee schedule,120.37% of custom fee schedule,5.5,100,,,fee schedule,Pays 100% Medicare OPPS,7.15,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,5.5,100,,,fee schedule,Pays 100% Medicare OPPS,4.95,234,
Blood test to if peptic ulcers are caused by a certain bacterium,3000707,CDM,302,RC,86677,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,16.85,100,,,fee schedule,Pays 100% Medicare OPPS,16.85,100,,,fee schedule,Pays 100% Medicare OPPS,16.85,100,,,fee schedule,Pays 100% Medicare OPPS,21.9,130,,,fee schedule,Pays 130% Medicare OPPS,21.97,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.18,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,22.85,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,16.85,100,,,fee schedule,Pays 100% Medicare OPPS,15.16,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,21.97,120.37,,,fee schedule,120.37% of custom fee schedule,16.85,100,,,fee schedule,Pays 100% Medicare OPPS,21.9,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,16.85,100,,,fee schedule,Pays 100% Medicare OPPS,15.16,234,
"CAROTENE, SERUM",3082380,CDM,301,RC,82380,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,9.22,100,,,fee schedule,Pays 100% Medicare OPPS,9.22,100,,,fee schedule,Pays 100% Medicare OPPS,9.22,100,,,fee schedule,Pays 100% Medicare OPPS,11.98,130,,,fee schedule,Pays 130% Medicare OPPS,13.96,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.4,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,14.52,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,9.22,100,,,fee schedule,Pays 100% Medicare OPPS,8.29,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,13.96,120.37,,,fee schedule,120.37% of custom fee schedule,9.22,100,,,fee schedule,Pays 100% Medicare OPPS,11.98,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,9.22,100,,,fee schedule,Pays 100% Medicare OPPS,8.29,234,
IGE,3082785,CDM,301,RC,83520,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,130,,,fee schedule,Pays 130% Medicare OPPS,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.61,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,20.38,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,15.54,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,15.54,234,
"GASTRIN, SERUM",3082941,CDM,301,RC,82941,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,17.63,100,,,fee schedule,Pays 100% Medicare OPPS,17.63,100,,,fee schedule,Pays 100% Medicare OPPS,17.63,100,,,fee schedule,Pays 100% Medicare OPPS,22.91,130,,,fee schedule,Pays 130% Medicare OPPS,26.7,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.98,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,27.76,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,17.63,100,,,fee schedule,Pays 100% Medicare OPPS,15.86,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,26.7,120.37,,,fee schedule,120.37% of custom fee schedule,17.63,100,,,fee schedule,Pays 100% Medicare OPPS,22.91,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,17.63,100,,,fee schedule,Pays 100% Medicare OPPS,15.86,234,
3RD HAPTOGLOBIN LEVEL,3083010,CDM,301,RC,83010,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,12.58,100,,,fee schedule,Pays 100% Medicare OPPS,12.58,100,,,fee schedule,Pays 100% Medicare OPPS,12.58,100,,,fee schedule,Pays 100% Medicare OPPS,16.35,130,,,fee schedule,Pays 130% Medicare OPPS,5.65,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.83,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,5.87,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,12.58,100,,,fee schedule,Pays 100% Medicare OPPS,11.32,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,5.65,120.37,,,fee schedule,120.37% of custom fee schedule,12.58,100,,,fee schedule,Pays 100% Medicare OPPS,16.35,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,12.58,100,,,fee schedule,Pays 100% Medicare OPPS,5.65,234,
ALKALINE PHOSPHATASE ISO,3084080,CDM,301,RC,84080,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,14.78,100,,,fee schedule,Pays 100% Medicare OPPS,14.78,100,,,fee schedule,Pays 100% Medicare OPPS,14.78,100,,,fee schedule,Pays 100% Medicare OPPS,19.21,130,,,fee schedule,Pays 130% Medicare OPPS,22.38,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.07,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,23.27,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,14.78,100,,,fee schedule,Pays 100% Medicare OPPS,13.3,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,22.38,120.37,,,fee schedule,120.37% of custom fee schedule,14.78,100,,,fee schedule,Pays 100% Medicare OPPS,19.21,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,14.78,100,,,fee schedule,Pays 100% Medicare OPPS,13.3,234,
URINALYSIS PORPHYRINS,3084120,CDM,301,RC,84120,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,14.71,100,,,fee schedule,Pays 100% Medicare OPPS,14.71,100,,,fee schedule,Pays 100% Medicare OPPS,14.71,100,,,fee schedule,Pays 100% Medicare OPPS,19.12,130,,,fee schedule,Pays 130% Medicare OPPS,22.27,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,23.16,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,14.71,100,,,fee schedule,Pays 100% Medicare OPPS,13.23,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,22.27,120.37,,,fee schedule,120.37% of custom fee schedule,14.71,100,,,fee schedule,Pays 100% Medicare OPPS,19.12,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,14.71,100,,,fee schedule,Pays 100% Medicare OPPS,13.23,234,
PROTOPORPHYRIN FREE RBC,3084202,CDM,301,RC,84202,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,14.35,100,,,fee schedule,Pays 100% Medicare OPPS,14.35,100,,,fee schedule,Pays 100% Medicare OPPS,14.35,100,,,fee schedule,Pays 100% Medicare OPPS,18.65,130,,,fee schedule,Pays 130% Medicare OPPS,21.73,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.63,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,22.59,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,14.35,100,,,fee schedule,Pays 100% Medicare OPPS,12.91,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,21.73,120.37,,,fee schedule,120.37% of custom fee schedule,14.35,100,,,fee schedule,Pays 100% Medicare OPPS,18.65,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,14.35,100,,,fee schedule,Pays 100% Medicare OPPS,12.91,234,
"Blood test, thyroid stimulating hormone (TSH)",3084443,CDM,301,RC,84443,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,16.8,100,,,fee schedule,Pays 100% Medicare OPPS,16.8,100,,,fee schedule,Pays 100% Medicare OPPS,16.8,100,,,fee schedule,Pays 100% Medicare OPPS,21.84,130,,,fee schedule,Pays 130% Medicare OPPS,25.42,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.13,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,26.44,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,16.8,100,,,fee schedule,Pays 100% Medicare OPPS,15.12,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,25.42,120.37,,,fee schedule,120.37% of custom fee schedule,16.8,100,,,fee schedule,Pays 100% Medicare OPPS,21.84,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,16.8,100,,,fee schedule,Pays 100% Medicare OPPS,15.12,234,
LAP STAIN,3085540,CDM,305,RC,85540,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,8.6,100,,,fee schedule,Pays 100% Medicare OPPS,8.6,100,,,fee schedule,Pays 100% Medicare OPPS,8.6,100,,,fee schedule,Pays 100% Medicare OPPS,11.18,130,,,fee schedule,Pays 130% Medicare OPPS,9.15,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.77,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,9.51,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,8.6,100,,,fee schedule,Pays 100% Medicare OPPS,7.74,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,9.15,120.37,,,fee schedule,120.37% of custom fee schedule,8.6,100,,,fee schedule,Pays 100% Medicare OPPS,11.18,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,8.6,100,,,fee schedule,Pays 100% Medicare OPPS,7.74,234,
LYSOZYME,3085549,CDM,305,RC,85549,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,24.37,130,,,fee schedule,Pays 130% Medicare OPPS,28.4,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.12,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,29.53,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,16.87,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,28.4,120.37,,,fee schedule,120.37% of custom fee schedule,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,24.37,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,18.75,100,,,fee schedule,Pays 100% Medicare OPPS,16.87,234,
ANA W/TITER,3086039,CDM,302,RC,86038,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,12.09,100,,,fee schedule,Pays 100% Medicare OPPS,12.09,100,,,fee schedule,Pays 100% Medicare OPPS,12.09,100,,,fee schedule,Pays 100% Medicare OPPS,15.71,130,,,fee schedule,Pays 130% Medicare OPPS,18.3,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.33,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,19.03,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,12.09,100,,,fee schedule,Pays 100% Medicare OPPS,10.88,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,18.3,120.37,,,fee schedule,120.37% of custom fee schedule,12.09,100,,,fee schedule,Pays 100% Medicare OPPS,15.71,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,12.09,100,,,fee schedule,Pays 100% Medicare OPPS,10.88,234,
ANTI DNASE B,3086215,CDM,302,RC,86215,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,13.25,100,,,fee schedule,Pays 100% Medicare OPPS,13.25,100,,,fee schedule,Pays 100% Medicare OPPS,13.25,100,,,fee schedule,Pays 100% Medicare OPPS,17.22,130,,,fee schedule,Pays 130% Medicare OPPS,20.05,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.51,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,20.85,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,13.25,100,,,fee schedule,Pays 100% Medicare OPPS,11.92,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,20.05,120.37,,,fee schedule,120.37% of custom fee schedule,13.25,100,,,fee schedule,Pays 100% Medicare OPPS,17.22,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,13.25,100,,,fee schedule,Pays 100% Medicare OPPS,11.92,234,
3RD LYME DISEASE,3086618,CDM,300,RC,86617,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,15.49,100,,,fee schedule,Pays 100% Medicare OPPS,15.49,100,,,fee schedule,Pays 100% Medicare OPPS,15.49,100,,,fee schedule,Pays 100% Medicare OPPS,20.13,130,,,fee schedule,Pays 130% Medicare OPPS,23.45,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.79,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,24.39,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,15.49,100,,,fee schedule,Pays 100% Medicare OPPS,13.94,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,23.45,120.37,,,fee schedule,120.37% of custom fee schedule,15.49,100,,,fee schedule,Pays 100% Medicare OPPS,20.13,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,15.49,100,,,fee schedule,Pays 100% Medicare OPPS,13.94,234,
Blood test to if peptic ulcers are caused by a certain bacterium,3086677,CDM,302,RC,86677,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,16.85,100,,,fee schedule,Pays 100% Medicare OPPS,16.85,100,,,fee schedule,Pays 100% Medicare OPPS,16.85,100,,,fee schedule,Pays 100% Medicare OPPS,21.9,130,,,fee schedule,Pays 130% Medicare OPPS,21.97,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.18,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,22.85,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,16.85,100,,,fee schedule,Pays 100% Medicare OPPS,15.16,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,21.97,120.37,,,fee schedule,120.37% of custom fee schedule,16.85,100,,,fee schedule,Pays 100% Medicare OPPS,21.9,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,16.85,100,,,fee schedule,Pays 100% Medicare OPPS,15.16,234,
Blood test to determine if antibodies exist for measles,3086765,CDM,302,RC,86765,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.13,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,20.28,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,234,
3RD TOXOPLASMOSIS IgG,3086777,CDM,302,RC,86777,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.7,130,,,fee schedule,Pays 130% Medicare OPPS,17.61,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.67,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,18.31,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.95,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,17.61,120.37,,,fee schedule,120.37% of custom fee schedule,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.7,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.95,234,
88307 SURGICAL PATHOLOGY LEVEL V,3200009,CDM,310,RC,88307,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,370.6,130,,,fee schedule,Pays 130% Medicare OPPS,160.45,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,266.86,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,166.86,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,235.46,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,160.45,120.37,,,fee schedule,120.37% of custom fee schedule,285.08,100,,,fee schedule,Pays 100% Medicare OPPS,370.6,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,146.9,370.6,
88309 SURGICAL PATHOLOGY LEVEL VI,3200010,CDM,310,RC,88309,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,588.69,100,,,fee schedule,Pays 100% Medicare OPPS,588.69,100,,,fee schedule,Pays 100% Medicare OPPS,588.69,100,,,fee schedule,Pays 100% Medicare OPPS,887.9,130,,,fee schedule,Pays 130% Medicare OPPS,226.03,120.37,,,fee schedule,120.37% of custom fee schedule,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,600.46,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,235.06,125.18,,,fee schedule,125.18% of custom fee schedule,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,588.69,100,,,fee schedule,Pays 100% Medicare OPPS,529.82,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,226.03,120.37,,,fee schedule,120.37% of custom fee schedule,683,100,,,fee schedule,Pays 100% Medicare OPPS,887.9,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,588.69,100,,,fee schedule,Pays 100% Medicare OPPS,146.9,887.9,
BIOPSY CHIBA NEEDLE,4000801,CDM,272,RC,,,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,234,90,,,percent of total billed charges,90% of total billed charges,91,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,150.8,58,,,percent of total billed charges,58% of total billed charges,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,221,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,52.96,234,
PT RE EVALUATION (OLD CHARGE) OLD,5097002,CDM,424,RC,97002,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,234,90,,,percent of total billed charges,90% of total billed charges,91,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,150.8,58,,,percent of total billed charges,58% of total billed charges,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,221,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,52.96,234,
PT RE EVALUATION (PER SESSION),5097164,CDM,424,RC,97164,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,66.07,100,,,fee schedule,Pays 100% Medicare OPPS,66.07,100,,,fee schedule,Pays 100% Medicare OPPS,66.07,100,,,fee schedule,Pays 100% Medicare OPPS,86,130,,,fee schedule,Pays 130% Medicare OPPS,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67.39,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,91,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,66.07,100,,,fee schedule,Pays 100% Medicare OPPS,59.46,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,66.15,100,,,fee schedule,Pays 100% Medicare OPPS,86,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,66.07,100,,,fee schedule,Pays 100% Medicare OPPS,52.96,234,
OT RE EVALUATION (PER SESSION),5197004,CDM,434,RC,97004,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,234,90,,,percent of total billed charges,90% of total billed charges,91,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,150.8,58,,,percent of total billed charges,58% of total billed charges,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,221,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,52.96,234,
"Debridement (for example, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps)",5197597,CDM,430,RC,97597,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,164.53,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,91,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,145.18,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.83,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,52.96,234,
RHYTHM STRIP CHG W EKG,5693041,CDM,730,RC,93041,HCPCS,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,65.72,130,,,fee schedule,Pays 130% Medicare OPPS,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,51,102,,,fee schedule,Pays 102% Medicare OPPS,234,90,,,percent of total billed charges,90% of total billed charges,91,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,45,90,,,fee schedule,Pays 90% Medicare OPPS,150.8,58,,,percent of total billed charges,58% of total billed charges,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,50.55,100,,,fee schedule,Pays 100% Medicare OPPS,65.72,130,,,fee schedule,Pays 130% Medicare OPPS,221,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,45,234,
SPLINT ELBOW POSTERIOR PRE-FORMED,7900515,CDM,274,RC,L3999,HCPCS,Both,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,234,90,,,percent of total billed charges,90% of total billed charges,91,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,150.8,58,,,percent of total billed charges,58% of total billed charges,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,221,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,52.96,234,
FORCEP BIOPSY MULTIBITE 1012,7905045,CDM,272,RC,,,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,234,90,,,percent of total billed charges,90% of total billed charges,91,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,150.8,58,,,percent of total billed charges,58% of total billed charges,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,221,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,52.96,234,
ABD BINDER 12 79-99440,7905420,CDM,270,RC,,,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,234,90,,,percent of total billed charges,90% of total billed charges,91,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,150.8,58,,,percent of total billed charges,58% of total billed charges,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,221,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,52.96,234,
CATH PED. FOLEY 6 FR.,7905953,CDM,270,RC,,,Outpatient,,,260,208,,221,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,234,90,,,percent of total billed charges,90% of total billed charges,91,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,178.62,68.7,,,percent of total billed charges,68.7% of total billed charges,208,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,150.8,58,,,percent of total billed charges,58% of total billed charges,52.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,221,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,52.96,234,
IV ADDITIONAL SEQUENTIAL INFUSION,1090767,CDM,760,RC,96367,HCPCS,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.8,102,,,fee schedule,Pays 102% Medicare OPPS,238.5,90,,,percent of total billed charges,90% of total billed charges,92.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,50.12,90,,,fee schedule,Pays 90% Medicare OPPS,153.7,58,,,percent of total billed charges,58% of total billed charges,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,59.34,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,225.25,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,50.12,238.5,
ALEXIS O WOUND PROTECT RETRACT 2.5-6CM,1570081,CDM,272,RC,,,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,238.5,90,,,percent of total billed charges,90% of total billed charges,92.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,153.7,58,,,percent of total billed charges,58% of total billed charges,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,225.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,53.98,238.5,
ALEXIS O WOUND PROTECT RETRACT 5-9CM,1570082,CDM,272,RC,,,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,238.5,90,,,percent of total billed charges,90% of total billed charges,92.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,153.7,58,,,percent of total billed charges,58% of total billed charges,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,225.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,53.98,238.5,
SINUS GUIDE CATHETER HANDLE SDKKLP,1570755,CDM,272,RC,,,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,238.5,90,,,percent of total billed charges,90% of total billed charges,92.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,153.7,58,,,percent of total billed charges,58% of total billed charges,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,225.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,53.98,238.5,
RECOVERY ROOM PER 15 MIN,1602200,CDM,710,RC,,,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,238.5,90,,,percent of total billed charges,90% of total billed charges,92.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,153.7,58,,,percent of total billed charges,58% of total billed charges,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,225.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,53.98,238.5,
CONSCIOUS SEDATION SCOPES,1700740,CDM,379,RC,99144,HCPCS,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,238.5,90,,,percent of total billed charges,90% of total billed charges,92.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,153.7,58,,,percent of total billed charges,58% of total billed charges,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,53.98,238.5,
ER NON-URGENT EMC,2000014,CDM,450,RC,99281,HCPCS,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,65.16,100,,,fee schedule,Pays 100% Medicare OPPS,65.16,100,,,fee schedule,Pays 100% Medicare OPPS,65.16,100,,,fee schedule,Pays 100% Medicare OPPS,85.85,130,,,fee schedule,Pays 130% Medicare OPPS,50,100,,,case rate,"ER level 1, Revenue Code 450 per visit $50.00",265,100,,,percent of total billed charges,671 dollar flat fee for ER,265,100,,,percent of total billed charges,671 dollar flat fee for ER,265,100,,,percent of total billed charges,671 dollar flat fee for ER,265,100,,,percent of total billed charges,671 dollar flat fee for ER,66.45,102,,,fee schedule,Pays 102% Medicare OPPS,238.5,90,,,percent of total billed charges,90% of total billed charges,92.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,65.16,100,,,fee schedule,Pays 100% Medicare OPPS,58.64,90,,,fee schedule,Pays 90% Medicare OPPS,153.7,58,,,percent of total billed charges,58% of total billed charges,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,66.04,100,,,fee schedule,Pays 100% Medicare OPPS,85.85,130,,,fee schedule,Pays 130% Medicare OPPS,225.25,85,,,percent of total billed charges,85% of total billed charges,65.16,100,,,fee schedule,Pays 100% Medicare OPPS,50,265,
REPAIR NAIL BED,2011760,CDM,450,RC,,,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,238.5,90,,,percent of total billed charges,90% of total billed charges,92.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,153.7,58,,,percent of total billed charges,58% of total billed charges,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,225.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,53.98,238.5,
TRIGGER POINT INJECTION SINGLE/MULTIPLE,2020552,CDM,761,RC,20552,HCPCS,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,310.88,130,,,fee schedule,Pays 130% Medicare OPPS,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,239.38,102,,,fee schedule,Pays 102% Medicare OPPS,238.5,90,,,percent of total billed charges,90% of total billed charges,92.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,211.22,90,,,fee schedule,Pays 90% Medicare OPPS,153.7,58,,,percent of total billed charges,58% of total billed charges,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,239.14,100,,,fee schedule,Pays 100% Medicare OPPS,310.88,130,,,fee schedule,Pays 130% Medicare OPPS,225.25,85,,,percent of total billed charges,85% of total billed charges,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,53.98,310.88,
IV ADDITIONAL SEQUENTIAL INFUSION,2090767,CDM,450,RC,96367,HCPCS,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.8,102,,,fee schedule,Pays 102% Medicare OPPS,238.5,90,,,percent of total billed charges,90% of total billed charges,92.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,50.12,90,,,fee schedule,Pays 90% Medicare OPPS,153.7,58,,,percent of total billed charges,58% of total billed charges,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,59.34,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,225.25,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,50.12,238.5,
LEVEL I EMERGENCY ROOM,2099281,CDM,450,RC,99281,HCPCS,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,65.16,100,,,fee schedule,Pays 100% Medicare OPPS,65.16,100,,,fee schedule,Pays 100% Medicare OPPS,65.16,100,,,fee schedule,Pays 100% Medicare OPPS,85.85,130,,,fee schedule,Pays 130% Medicare OPPS,50,100,,,case rate,"ER level 1, Revenue Code 450 per visit $50.00",265,100,,,percent of total billed charges,671 dollar flat fee for ER,265,100,,,percent of total billed charges,671 dollar flat fee for ER,265,100,,,percent of total billed charges,671 dollar flat fee for ER,265,100,,,percent of total billed charges,671 dollar flat fee for ER,66.45,102,,,fee schedule,Pays 102% Medicare OPPS,238.5,90,,,percent of total billed charges,90% of total billed charges,92.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,65.16,100,,,fee schedule,Pays 100% Medicare OPPS,58.64,90,,,fee schedule,Pays 90% Medicare OPPS,153.7,58,,,percent of total billed charges,58% of total billed charges,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,66.04,100,,,fee schedule,Pays 100% Medicare OPPS,85.85,130,,,fee schedule,Pays 130% Medicare OPPS,225.25,85,,,percent of total billed charges,85% of total billed charges,65.16,100,,,fee schedule,Pays 100% Medicare OPPS,50,265,
AUGMENTIN SUSP 600MG/5ML 75ML,2600708,CDM,637,RC,,,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,238.5,90,,,percent of total billed charges,90% of total billed charges,92.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,153.7,58,,,percent of total billed charges,58% of total billed charges,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,225.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,53.98,238.5,
SINCALIDE (KINEVAC) VIAL 5MCG,2602262,CDM,636,RC,J2805,HCPCS,Both,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,238.5,90,,,percent of total billed charges,90% of total billed charges,92.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,153.7,58,,,percent of total billed charges,58% of total billed charges,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,225.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,53.98,238.5,
ANTI-PARIETAL CELL,3000019,CDM,302,RC,86255,HCPCS,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,,,fee schedule,Pays 130% Medicare OPPS,18.25,120.37,,,fee schedule,120.37% of custom fee schedule,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.29,102,,,fee schedule,Pays 102% Medicare OPPS,238.5,90,,,percent of total billed charges,90% of total billed charges,18.98,125.18,,,fee schedule,125.18% of custom fee schedule,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,10.84,90,,,fee schedule,Pays 90% Medicare OPPS,153.7,58,,,percent of total billed charges,58% of total billed charges,18.25,120.37,,,fee schedule,120.37% of custom fee schedule,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,,,fee schedule,Pays 130% Medicare OPPS,225.25,85,,,percent of total billed charges,85% of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,10.84,238.5,
3RD ACETYLCHOLINE RECEPTOR BLOCKING AU,3000559,CDM,301,RC,83519,HCPCS,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,23.92,130,,,fee schedule,Pays 130% Medicare OPPS,20.45,120.37,,,fee schedule,120.37% of custom fee schedule,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.76,102,,,fee schedule,Pays 102% Medicare OPPS,238.5,90,,,percent of total billed charges,90% of total billed charges,21.27,125.18,,,fee schedule,125.18% of custom fee schedule,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.55,90,,,fee schedule,Pays 90% Medicare OPPS,153.7,58,,,percent of total billed charges,58% of total billed charges,20.45,120.37,,,fee schedule,120.37% of custom fee schedule,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,23.92,130,,,fee schedule,Pays 130% Medicare OPPS,225.25,85,,,percent of total billed charges,85% of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.55,238.5,
NEURON SPECIFIC ENOLASE,3000579,CDM,302,RC,86316,HCPCS,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,27.05,130,,,fee schedule,Pays 130% Medicare OPPS,31.49,120.37,,,fee schedule,120.37% of custom fee schedule,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,21.22,102,,,fee schedule,Pays 102% Medicare OPPS,238.5,90,,,percent of total billed charges,90% of total billed charges,32.75,125.18,,,fee schedule,125.18% of custom fee schedule,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,18.72,90,,,fee schedule,Pays 90% Medicare OPPS,153.7,58,,,percent of total billed charges,58% of total billed charges,31.49,120.37,,,fee schedule,120.37% of custom fee schedule,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,27.05,130,,,fee schedule,Pays 130% Medicare OPPS,225.25,85,,,percent of total billed charges,85% of total billed charges,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,18.72,238.5,
VITAMIN K LEVEL,3000608,CDM,300,RC,84597,HCPCS,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,13.72,100,,,fee schedule,Pays 100% Medicare OPPS,13.72,100,,,fee schedule,Pays 100% Medicare OPPS,13.72,100,,,fee schedule,Pays 100% Medicare OPPS,17.83,130,,,fee schedule,Pays 130% Medicare OPPS,20.75,120.37,,,fee schedule,120.37% of custom fee schedule,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.99,102,,,fee schedule,Pays 102% Medicare OPPS,238.5,90,,,percent of total billed charges,90% of total billed charges,21.58,125.18,,,fee schedule,125.18% of custom fee schedule,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,13.72,100,,,fee schedule,Pays 100% Medicare OPPS,12.34,90,,,fee schedule,Pays 90% Medicare OPPS,153.7,58,,,percent of total billed charges,58% of total billed charges,20.75,120.37,,,fee schedule,120.37% of custom fee schedule,13.72,100,,,fee schedule,Pays 100% Medicare OPPS,17.83,130,,,fee schedule,Pays 130% Medicare OPPS,225.25,85,,,percent of total billed charges,85% of total billed charges,13.72,100,,,fee schedule,Pays 100% Medicare OPPS,12.34,238.5,
LEGIONELLA ANTIGEN FLUID/WASHING EIA,3000610,CDM,300,RC,87278,HCPCS,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,15.6,100,,,fee schedule,Pays 100% Medicare OPPS,15.6,100,,,fee schedule,Pays 100% Medicare OPPS,15.6,100,,,fee schedule,Pays 100% Medicare OPPS,20.28,130,,,fee schedule,Pays 130% Medicare OPPS,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.91,102,,,fee schedule,Pays 102% Medicare OPPS,238.5,90,,,percent of total billed charges,90% of total billed charges,18.88,125.18,,,fee schedule,125.18% of custom fee schedule,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,15.6,100,,,fee schedule,Pays 100% Medicare OPPS,14.04,90,,,fee schedule,Pays 90% Medicare OPPS,153.7,58,,,percent of total billed charges,58% of total billed charges,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,15.6,100,,,fee schedule,Pays 100% Medicare OPPS,20.28,130,,,fee schedule,Pays 130% Medicare OPPS,225.25,85,,,percent of total billed charges,85% of total billed charges,15.6,100,,,fee schedule,Pays 100% Medicare OPPS,14.04,238.5,
"Complete blood cell count, with differential white blood cells, automated",3000742,CDM,300,RC,85025,HCPCS,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,7.77,100,,,fee schedule,Pays 100% Medicare OPPS,7.77,100,,,fee schedule,Pays 100% Medicare OPPS,7.77,100,,,fee schedule,Pays 100% Medicare OPPS,10.1,130,,,fee schedule,Pays 130% Medicare OPPS,11.76,120.37,,,fee schedule,120.37% of custom fee schedule,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,7.92,102,,,fee schedule,Pays 102% Medicare OPPS,238.5,90,,,percent of total billed charges,90% of total billed charges,12.23,125.18,,,fee schedule,125.18% of custom fee schedule,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,7.77,100,,,fee schedule,Pays 100% Medicare OPPS,6.99,90,,,fee schedule,Pays 90% Medicare OPPS,153.7,58,,,percent of total billed charges,58% of total billed charges,11.76,120.37,,,fee schedule,120.37% of custom fee schedule,7.77,100,,,fee schedule,Pays 100% Medicare OPPS,10.1,130,,,fee schedule,Pays 130% Medicare OPPS,225.25,85,,,percent of total billed charges,85% of total billed charges,7.77,100,,,fee schedule,Pays 100% Medicare OPPS,6.99,238.5,
RC AGT PHASE CROSSMATCH,3008692,CDM,300,RC,86922,HCPCS,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,179.8,130,,,fee schedule,Pays 130% Medicare OPPS,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,136.65,102,,,fee schedule,Pays 102% Medicare OPPS,238.5,90,,,percent of total billed charges,90% of total billed charges,92.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,120.57,90,,,fee schedule,Pays 90% Medicare OPPS,153.7,58,,,percent of total billed charges,58% of total billed charges,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,138.31,100,,,fee schedule,Pays 100% Medicare OPPS,179.8,130,,,fee schedule,Pays 130% Medicare OPPS,225.25,85,,,percent of total billed charges,85% of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,53.98,238.5,
"DILANTIN,FREE LEVEL",3080186,CDM,301,RC,80186,HCPCS,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,13.76,100,,,fee schedule,Pays 100% Medicare OPPS,13.76,100,,,fee schedule,Pays 100% Medicare OPPS,13.76,100,,,fee schedule,Pays 100% Medicare OPPS,17.88,130,,,fee schedule,Pays 130% Medicare OPPS,20.84,120.37,,,fee schedule,120.37% of custom fee schedule,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.03,102,,,fee schedule,Pays 102% Medicare OPPS,238.5,90,,,percent of total billed charges,90% of total billed charges,21.67,125.18,,,fee schedule,125.18% of custom fee schedule,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,13.76,100,,,fee schedule,Pays 100% Medicare OPPS,12.38,90,,,fee schedule,Pays 90% Medicare OPPS,153.7,58,,,percent of total billed charges,58% of total billed charges,20.84,120.37,,,fee schedule,120.37% of custom fee schedule,13.76,100,,,fee schedule,Pays 100% Medicare OPPS,17.88,130,,,fee schedule,Pays 130% Medicare OPPS,225.25,85,,,percent of total billed charges,85% of total billed charges,13.76,100,,,fee schedule,Pays 100% Medicare OPPS,12.38,238.5,
Blood test that measures the amount of iron carried in the blood,3083550,CDM,301,RC,83550,HCPCS,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,8.74,100,,,fee schedule,Pays 100% Medicare OPPS,8.74,100,,,fee schedule,Pays 100% Medicare OPPS,8.74,100,,,fee schedule,Pays 100% Medicare OPPS,11.36,130,,,fee schedule,Pays 130% Medicare OPPS,13.23,120.37,,,fee schedule,120.37% of custom fee schedule,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.91,102,,,fee schedule,Pays 102% Medicare OPPS,238.5,90,,,percent of total billed charges,90% of total billed charges,13.76,125.18,,,fee schedule,125.18% of custom fee schedule,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,8.74,100,,,fee schedule,Pays 100% Medicare OPPS,7.86,90,,,fee schedule,Pays 90% Medicare OPPS,153.7,58,,,percent of total billed charges,58% of total billed charges,13.23,120.37,,,fee schedule,120.37% of custom fee schedule,8.74,100,,,fee schedule,Pays 100% Medicare OPPS,11.36,130,,,fee schedule,Pays 130% Medicare OPPS,225.25,85,,,percent of total billed charges,85% of total billed charges,8.74,100,,,fee schedule,Pays 100% Medicare OPPS,7.86,238.5,
"Complete blood cell count, with differential white blood cells, automated",3085025,CDM,305,RC,85025,HCPCS,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,7.77,100,,,fee schedule,Pays 100% Medicare OPPS,7.77,100,,,fee schedule,Pays 100% Medicare OPPS,7.77,100,,,fee schedule,Pays 100% Medicare OPPS,10.1,130,,,fee schedule,Pays 130% Medicare OPPS,11.76,120.37,,,fee schedule,120.37% of custom fee schedule,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,7.92,102,,,fee schedule,Pays 102% Medicare OPPS,238.5,90,,,percent of total billed charges,90% of total billed charges,12.23,125.18,,,fee schedule,125.18% of custom fee schedule,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,7.77,100,,,fee schedule,Pays 100% Medicare OPPS,6.99,90,,,fee schedule,Pays 90% Medicare OPPS,153.7,58,,,percent of total billed charges,58% of total billed charges,11.76,120.37,,,fee schedule,120.37% of custom fee schedule,7.77,100,,,fee schedule,Pays 100% Medicare OPPS,10.1,130,,,fee schedule,Pays 130% Medicare OPPS,225.25,85,,,percent of total billed charges,85% of total billed charges,7.77,100,,,fee schedule,Pays 100% Medicare OPPS,6.99,238.5,
INTRINSIC FACTOR BLK AB,3086340,CDM,300,RC,86340,HCPCS,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,19.6,130,,,fee schedule,Pays 130% Medicare OPPS,22.81,120.37,,,fee schedule,120.37% of custom fee schedule,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.38,102,,,fee schedule,Pays 102% Medicare OPPS,238.5,90,,,percent of total billed charges,90% of total billed charges,23.72,125.18,,,fee schedule,125.18% of custom fee schedule,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,13.57,90,,,fee schedule,Pays 90% Medicare OPPS,153.7,58,,,percent of total billed charges,58% of total billed charges,22.81,120.37,,,fee schedule,120.37% of custom fee schedule,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,19.6,130,,,fee schedule,Pays 130% Medicare OPPS,225.25,85,,,percent of total billed charges,85% of total billed charges,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,13.57,238.5,
NOCARDIA ANTIBODY,3086744,CDM,302,RC,86744,HCPCS,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,15.99,100,,,fee schedule,Pays 100% Medicare OPPS,15.99,100,,,fee schedule,Pays 100% Medicare OPPS,15.99,100,,,fee schedule,Pays 100% Medicare OPPS,20.78,130,,,fee schedule,Pays 130% Medicare OPPS,19.97,120.37,,,fee schedule,120.37% of custom fee schedule,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.3,102,,,fee schedule,Pays 102% Medicare OPPS,238.5,90,,,percent of total billed charges,90% of total billed charges,20.77,125.18,,,fee schedule,125.18% of custom fee schedule,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,15.99,100,,,fee schedule,Pays 100% Medicare OPPS,14.39,90,,,fee schedule,Pays 90% Medicare OPPS,153.7,58,,,percent of total billed charges,58% of total billed charges,19.97,120.37,,,fee schedule,120.37% of custom fee schedule,15.99,100,,,fee schedule,Pays 100% Medicare OPPS,20.78,130,,,fee schedule,Pays 130% Medicare OPPS,225.25,85,,,percent of total billed charges,85% of total billed charges,15.99,100,,,fee schedule,Pays 100% Medicare OPPS,14.39,238.5,
.IMMEDIATE SPIN (X-M),3086920,CDM,300,RC,86920,HCPCS,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,179.8,130,,,fee schedule,Pays 130% Medicare OPPS,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,136.65,102,,,fee schedule,Pays 102% Medicare OPPS,238.5,90,,,percent of total billed charges,90% of total billed charges,92.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,120.57,90,,,fee schedule,Pays 90% Medicare OPPS,153.7,58,,,percent of total billed charges,58% of total billed charges,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,138.31,100,,,fee schedule,Pays 100% Medicare OPPS,179.8,130,,,fee schedule,Pays 130% Medicare OPPS,225.25,85,,,percent of total billed charges,85% of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,53.98,238.5,
"Complete blood cell count, with differential white blood cells, automated",3099005,CDM,300,RC,85025,HCPCS,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,7.77,100,,,fee schedule,Pays 100% Medicare OPPS,7.77,100,,,fee schedule,Pays 100% Medicare OPPS,7.77,100,,,fee schedule,Pays 100% Medicare OPPS,10.1,130,,,fee schedule,Pays 130% Medicare OPPS,11.76,120.37,,,fee schedule,120.37% of custom fee schedule,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,7.92,102,,,fee schedule,Pays 102% Medicare OPPS,238.5,90,,,percent of total billed charges,90% of total billed charges,12.23,125.18,,,fee schedule,125.18% of custom fee schedule,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,7.77,100,,,fee schedule,Pays 100% Medicare OPPS,6.99,90,,,fee schedule,Pays 90% Medicare OPPS,153.7,58,,,percent of total billed charges,58% of total billed charges,11.76,120.37,,,fee schedule,120.37% of custom fee schedule,7.77,100,,,fee schedule,Pays 100% Medicare OPPS,10.1,130,,,fee schedule,Pays 130% Medicare OPPS,225.25,85,,,percent of total billed charges,85% of total billed charges,7.77,100,,,fee schedule,Pays 100% Medicare OPPS,6.99,238.5,
Measure of lung function and gas exchange,5594240,CDM,460,RC,94727,HCPCS,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,125.41,100,,,fee schedule,Pays 100% Medicare OPPS,125.41,100,,,fee schedule,Pays 100% Medicare OPPS,125.41,100,,,fee schedule,Pays 100% Medicare OPPS,166.29,130,,,fee schedule,Pays 130% Medicare OPPS,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,127.92,102,,,fee schedule,Pays 102% Medicare OPPS,238.5,90,,,percent of total billed charges,90% of total billed charges,92.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,125.41,100,,,fee schedule,Pays 100% Medicare OPPS,112.87,90,,,fee schedule,Pays 90% Medicare OPPS,153.7,58,,,percent of total billed charges,58% of total billed charges,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,127.91,100,,,fee schedule,Pays 100% Medicare OPPS,166.29,130,,,fee schedule,Pays 130% Medicare OPPS,225.25,85,,,percent of total billed charges,85% of total billed charges,125.41,100,,,fee schedule,Pays 100% Medicare OPPS,53.98,238.5,
ABD BINDER 9 79-99430,7905155,CDM,270,RC,,,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,238.5,90,,,percent of total billed charges,90% of total billed charges,92.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,153.7,58,,,percent of total billed charges,58% of total billed charges,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,225.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,53.98,238.5,
TRACHEOSTOMY TUBE SZ 6 DCT,7905572,CDM,272,RC,,,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,238.5,90,,,percent of total billed charges,90% of total billed charges,92.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,153.7,58,,,percent of total billed charges,58% of total billed charges,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,225.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,53.98,238.5,
TRACHEOSTOMY TUBE SZ 8 DCT,7905573,CDM,272,RC,,,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,238.5,90,,,percent of total billed charges,90% of total billed charges,92.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,153.7,58,,,percent of total billed charges,58% of total billed charges,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,225.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,53.98,238.5,
GASTROSTOMY TUBE ENDOVIVE 20FR.,7950205,CDM,270,RC,,,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,238.5,90,,,percent of total billed charges,90% of total billed charges,92.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,153.7,58,,,percent of total billed charges,58% of total billed charges,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,225.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,53.98,238.5,
BIS SENSOR QUATRO 186-0106,7950238,CDM,270,RC,,,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,238.5,90,,,percent of total billed charges,90% of total billed charges,92.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,153.7,58,,,percent of total billed charges,58% of total billed charges,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,225.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,53.98,238.5,
ACTIVITY THERAPY 45 MIN,9000176,CDM,904,RC,,,Outpatient,,,265,212,,225.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,149.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,238.5,90,,,percent of total billed charges,90% of total billed charges,92.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,182.06,68.7,,,percent of total billed charges,68.7% of total billed charges,212,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,153.7,58,,,percent of total billed charges,58% of total billed charges,53.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,53.98,238.5,
ZOVIRAX OINT 5% 5GM,2600468,CDM,637,RC,,,Outpatient,,,270,216,,229.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,152.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,152.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,152.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,152.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,243,90,,,percent of total billed charges,90% of total billed charges,94.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,185.49,68.7,,,percent of total billed charges,68.7% of total billed charges,216,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,156.6,58,,,percent of total billed charges,58% of total billed charges,55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,229.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,55,243,
PELVIC SLING SAM II SMALL,7905335,CDM,274,RC,L3670,HCPCS,Both,,,270,216,,229.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,243,90,,,percent of total billed charges,90% of total billed charges,94.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,185.49,68.7,,,percent of total billed charges,68.7% of total billed charges,216,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,156.6,58,,,percent of total billed charges,58% of total billed charges,55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,229.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,55,243,
PELVIC SLING SAM II MEDIUM,7905336,CDM,274,RC,L3670,HCPCS,Both,,,270,216,,229.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,243,90,,,percent of total billed charges,90% of total billed charges,94.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,185.49,68.7,,,percent of total billed charges,68.7% of total billed charges,216,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,156.6,58,,,percent of total billed charges,58% of total billed charges,55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,229.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,55,243,
PELVIC SLING SAM II LARGE,7905337,CDM,274,RC,L3670,HCPCS,Both,,,270,216,,229.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,243,90,,,percent of total billed charges,90% of total billed charges,94.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,185.49,68.7,,,percent of total billed charges,68.7% of total billed charges,216,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,156.6,58,,,percent of total billed charges,58% of total billed charges,55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,229.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,55,243,
THORACENTESIS KIT,7905678,CDM,270,RC,,,Outpatient,,,270,216,,229.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,152.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,152.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,152.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,152.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,243,90,,,percent of total billed charges,90% of total billed charges,94.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,185.49,68.7,,,percent of total billed charges,68.7% of total billed charges,216,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,156.6,58,,,percent of total billed charges,58% of total billed charges,55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,229.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,55,243,
SUTURE 3-0 VICRYL J110T,1570558,CDM,272,RC,,,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,56.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,247.5,90,,,percent of total billed charges,90% of total billed charges,96.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,159.5,58,,,percent of total billed charges,58% of total billed charges,56.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,233.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,56.02,247.5,
Chemical test of the blood to measure presence or concentration of a substance in the blood,3000021,CDM,302,RC,83516,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.76,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,16.84,125.18,,,fee schedule,125.18% of custom fee schedule,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,247.5,
Test of body fluid other than blood to assess for bacteria,3000069,CDM,306,RC,87070,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.2,130,,,fee schedule,Pays 130% Medicare OPPS,13.04,120.37,,,fee schedule,120.37% of custom fee schedule,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.79,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,13.56,125.18,,,fee schedule,125.18% of custom fee schedule,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,7.75,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,13.04,120.37,,,fee schedule,120.37% of custom fee schedule,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.2,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,7.75,247.5,
DISOPYRAMIDE LEVEL,3000085,CDM,301,RC,80299,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.01,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,18.95,125.18,,,fee schedule,125.18% of custom fee schedule,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,247.5,
DNA ANTIBODIES (dsDNA),3000086,CDM,302,RC,86225,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,13.74,100,,,fee schedule,Pays 100% Medicare OPPS,13.74,100,,,fee schedule,Pays 100% Medicare OPPS,13.74,100,,,fee schedule,Pays 100% Medicare OPPS,17.86,130,,,fee schedule,Pays 130% Medicare OPPS,20.8,120.37,,,fee schedule,120.37% of custom fee schedule,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.01,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,21.63,125.18,,,fee schedule,125.18% of custom fee schedule,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,13.74,100,,,fee schedule,Pays 100% Medicare OPPS,12.36,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,20.8,120.37,,,fee schedule,120.37% of custom fee schedule,13.74,100,,,fee schedule,Pays 100% Medicare OPPS,17.86,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,13.74,100,,,fee schedule,Pays 100% Medicare OPPS,12.36,247.5,
"DRUG SCREEN, INDUS I,UA",3000090,CDM,301,RC,80377,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,56.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,247.5,90,,,percent of total billed charges,90% of total billed charges,96.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,159.5,58,,,percent of total billed charges,58% of total billed charges,56.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,233.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,56.02,247.5,
"GIARDIA, IgG, IgM (SERUM)",3000124,CDM,302,RC,86674,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,14.72,100,,,fee schedule,Pays 100% Medicare OPPS,14.72,100,,,fee schedule,Pays 100% Medicare OPPS,14.72,100,,,fee schedule,Pays 100% Medicare OPPS,19.13,130,,,fee schedule,Pays 130% Medicare OPPS,22.27,120.37,,,fee schedule,120.37% of custom fee schedule,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.01,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,23.16,125.18,,,fee schedule,125.18% of custom fee schedule,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,14.72,100,,,fee schedule,Pays 100% Medicare OPPS,13.24,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,22.27,120.37,,,fee schedule,120.37% of custom fee schedule,14.72,100,,,fee schedule,Pays 100% Medicare OPPS,19.13,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,14.72,100,,,fee schedule,Pays 100% Medicare OPPS,13.24,247.5,
".....GIARDIA ANTIGEN, STOOL",3000136,CDM,302,RC,87329,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,15.57,130,,,fee schedule,Pays 130% Medicare OPPS,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.21,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,18.88,125.18,,,fee schedule,125.18% of custom fee schedule,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,10.78,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,15.57,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,10.78,247.5,
Test of body fluid other than blood to assess for bacteria,3000553,CDM,306,RC,87070,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.2,130,,,fee schedule,Pays 130% Medicare OPPS,13.04,120.37,,,fee schedule,120.37% of custom fee schedule,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.79,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,13.56,125.18,,,fee schedule,125.18% of custom fee schedule,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,7.75,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,13.04,120.37,,,fee schedule,120.37% of custom fee schedule,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.2,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,7.75,247.5,
AMIKACIN PEAK,3000587,CDM,301,RC,80150,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,19.6,130,,,fee schedule,Pays 130% Medicare OPPS,22.81,120.37,,,fee schedule,120.37% of custom fee schedule,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.38,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,23.72,125.18,,,fee schedule,125.18% of custom fee schedule,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,13.57,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,22.81,120.37,,,fee schedule,120.37% of custom fee schedule,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,19.6,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,13.57,247.5,
Culture of the urine to determine bacterial infection,3000811,CDM,306,RC,87088,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,8.09,100,,,fee schedule,Pays 100% Medicare OPPS,8.09,100,,,fee schedule,Pays 100% Medicare OPPS,8.09,100,,,fee schedule,Pays 100% Medicare OPPS,10.51,130,,,fee schedule,Pays 130% Medicare OPPS,12.25,120.37,,,fee schedule,120.37% of custom fee schedule,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.25,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,12.74,125.18,,,fee schedule,125.18% of custom fee schedule,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,8.09,100,,,fee schedule,Pays 100% Medicare OPPS,7.28,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,12.25,120.37,,,fee schedule,120.37% of custom fee schedule,8.09,100,,,fee schedule,Pays 100% Medicare OPPS,10.51,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,8.09,100,,,fee schedule,Pays 100% Medicare OPPS,7.28,247.5,
AMIKACIN TROUGH,3080150,CDM,301,RC,80150,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,19.6,130,,,fee schedule,Pays 130% Medicare OPPS,22.81,120.37,,,fee schedule,120.37% of custom fee schedule,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.38,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,23.72,125.18,,,fee schedule,125.18% of custom fee schedule,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,13.57,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,22.81,120.37,,,fee schedule,120.37% of custom fee schedule,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,19.6,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,15.08,100,,,fee schedule,Pays 100% Medicare OPPS,13.57,247.5,
ELAVIL LEVEL,3080152,CDM,301,RC,80152,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,56.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,247.5,90,,,percent of total billed charges,90% of total billed charges,96.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,159.5,58,,,percent of total billed charges,58% of total billed charges,56.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,233.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,56.02,247.5,
QUINIDINE LEVEL,3080194,CDM,301,RC,80194,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,14.6,100,,,fee schedule,Pays 100% Medicare OPPS,14.6,100,,,fee schedule,Pays 100% Medicare OPPS,14.6,100,,,fee schedule,Pays 100% Medicare OPPS,18.98,130,,,fee schedule,Pays 130% Medicare OPPS,22.09,120.37,,,fee schedule,120.37% of custom fee schedule,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.89,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,22.97,125.18,,,fee schedule,125.18% of custom fee schedule,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,14.6,100,,,fee schedule,Pays 100% Medicare OPPS,13.14,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,22.09,120.37,,,fee schedule,120.37% of custom fee schedule,14.6,100,,,fee schedule,Pays 100% Medicare OPPS,18.98,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,14.6,100,,,fee schedule,Pays 100% Medicare OPPS,13.14,247.5,
.HLA CLASS 1 LOCUS,3081373,CDM,307,RC,81373,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,127.43,100,,,fee schedule,Pays 100% Medicare OPPS,127.43,100,,,fee schedule,Pays 100% Medicare OPPS,127.43,100,,,fee schedule,Pays 100% Medicare OPPS,165.65,130,,,fee schedule,Pays 130% Medicare OPPS,118.44,120.37,,,fee schedule,120.37% of custom fee schedule,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,129.97,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,123.18,125.18,,,fee schedule,125.18% of custom fee schedule,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,127.43,100,,,fee schedule,Pays 100% Medicare OPPS,114.68,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,118.44,120.37,,,fee schedule,120.37% of custom fee schedule,127.43,100,,,fee schedule,Pays 100% Medicare OPPS,165.65,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,127.43,100,,,fee schedule,Pays 100% Medicare OPPS,114.68,247.5,
.HLA CLASS 2 ANTIGEN,3081377,CDM,307,RC,81377,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,94.74,100,,,fee schedule,Pays 100% Medicare OPPS,94.74,100,,,fee schedule,Pays 100% Medicare OPPS,94.74,100,,,fee schedule,Pays 100% Medicare OPPS,123.16,130,,,fee schedule,Pays 130% Medicare OPPS,48.15,120.37,,,fee schedule,120.37% of custom fee schedule,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,96.63,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,50.07,125.18,,,fee schedule,125.18% of custom fee schedule,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,94.74,100,,,fee schedule,Pays 100% Medicare OPPS,85.26,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,48.15,120.37,,,fee schedule,120.37% of custom fee schedule,94.74,100,,,fee schedule,Pays 100% Medicare OPPS,123.16,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,94.74,100,,,fee schedule,Pays 100% Medicare OPPS,48.15,247.5,
Urine test to measure albumin,3082043,CDM,307,RC,82043,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,5.78,100,,,fee schedule,Pays 100% Medicare OPPS,5.78,100,,,fee schedule,Pays 100% Medicare OPPS,5.78,100,,,fee schedule,Pays 100% Medicare OPPS,7.51,130,,,fee schedule,Pays 130% Medicare OPPS,8.76,120.37,,,fee schedule,120.37% of custom fee schedule,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.89,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,9.11,125.18,,,fee schedule,125.18% of custom fee schedule,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,5.78,100,,,fee schedule,Pays 100% Medicare OPPS,5.2,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,8.76,120.37,,,fee schedule,120.37% of custom fee schedule,5.78,100,,,fee schedule,Pays 100% Medicare OPPS,7.51,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,5.78,100,,,fee schedule,Pays 100% Medicare OPPS,5.2,247.5,
BETA-2-MICROGLOBULIN,3082232,CDM,301,RC,82232,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,16.18,100,,,fee schedule,Pays 100% Medicare OPPS,16.18,100,,,fee schedule,Pays 100% Medicare OPPS,16.18,100,,,fee schedule,Pays 100% Medicare OPPS,21.03,130,,,fee schedule,Pays 130% Medicare OPPS,24.5,120.37,,,fee schedule,120.37% of custom fee schedule,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.5,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,25.47,125.18,,,fee schedule,125.18% of custom fee schedule,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,16.18,100,,,fee schedule,Pays 100% Medicare OPPS,14.56,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,24.5,120.37,,,fee schedule,120.37% of custom fee schedule,16.18,100,,,fee schedule,Pays 100% Medicare OPPS,21.03,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,16.18,100,,,fee schedule,Pays 100% Medicare OPPS,14.56,247.5,
G6PD QUANT,3082955,CDM,301,RC,82955,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,9.69,100,,,fee schedule,Pays 100% Medicare OPPS,9.69,100,,,fee schedule,Pays 100% Medicare OPPS,9.69,100,,,fee schedule,Pays 100% Medicare OPPS,12.61,130,,,fee schedule,Pays 130% Medicare OPPS,11.82,120.37,,,fee schedule,120.37% of custom fee schedule,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.89,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,12.29,125.18,,,fee schedule,125.18% of custom fee schedule,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,9.69,100,,,fee schedule,Pays 100% Medicare OPPS,8.72,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,11.82,120.37,,,fee schedule,120.37% of custom fee schedule,9.69,100,,,fee schedule,Pays 100% Medicare OPPS,12.61,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,9.69,100,,,fee schedule,Pays 100% Medicare OPPS,8.72,247.5,
"17 KETOSTEROIDS, TOTAL",3083586,CDM,301,RC,83586,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,12.8,100,,,fee schedule,Pays 100% Medicare OPPS,12.8,100,,,fee schedule,Pays 100% Medicare OPPS,12.8,100,,,fee schedule,Pays 100% Medicare OPPS,16.64,130,,,fee schedule,Pays 130% Medicare OPPS,19.02,120.37,,,fee schedule,120.37% of custom fee schedule,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.05,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,19.78,125.18,,,fee schedule,125.18% of custom fee schedule,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,12.8,100,,,fee schedule,Pays 100% Medicare OPPS,11.52,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,19.02,120.37,,,fee schedule,120.37% of custom fee schedule,12.8,100,,,fee schedule,Pays 100% Medicare OPPS,16.64,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,12.8,100,,,fee schedule,Pays 100% Medicare OPPS,11.52,247.5,
Blood test to measure level of prealbumin,3084134,CDM,301,RC,84134,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,14.59,100,,,fee schedule,Pays 100% Medicare OPPS,14.59,100,,,fee schedule,Pays 100% Medicare OPPS,14.59,100,,,fee schedule,Pays 100% Medicare OPPS,18.96,130,,,fee schedule,Pays 130% Medicare OPPS,22.08,120.37,,,fee schedule,120.37% of custom fee schedule,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.88,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,22.96,125.18,,,fee schedule,125.18% of custom fee schedule,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,14.59,100,,,fee schedule,Pays 100% Medicare OPPS,13.13,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,22.08,120.37,,,fee schedule,120.37% of custom fee schedule,14.59,100,,,fee schedule,Pays 100% Medicare OPPS,18.96,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,14.59,100,,,fee schedule,Pays 100% Medicare OPPS,13.13,247.5,
VITAMIN E LEVEL,3084446,CDM,301,RC,84446,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,14.18,100,,,fee schedule,Pays 100% Medicare OPPS,14.18,100,,,fee schedule,Pays 100% Medicare OPPS,14.18,100,,,fee schedule,Pays 100% Medicare OPPS,18.43,130,,,fee schedule,Pays 130% Medicare OPPS,21.46,120.37,,,fee schedule,120.37% of custom fee schedule,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.46,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,22.32,125.18,,,fee schedule,125.18% of custom fee schedule,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,14.18,100,,,fee schedule,Pays 100% Medicare OPPS,12.76,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,21.46,120.37,,,fee schedule,120.37% of custom fee schedule,14.18,100,,,fee schedule,Pays 100% Medicare OPPS,18.43,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,14.18,100,,,fee schedule,Pays 100% Medicare OPPS,12.76,247.5,
ANTI DNA DOUBLE STRANDED AB,3086225,CDM,302,RC,86225,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,13.74,100,,,fee schedule,Pays 100% Medicare OPPS,13.74,100,,,fee schedule,Pays 100% Medicare OPPS,13.74,100,,,fee schedule,Pays 100% Medicare OPPS,17.86,130,,,fee schedule,Pays 130% Medicare OPPS,20.8,120.37,,,fee schedule,120.37% of custom fee schedule,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.01,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,21.63,125.18,,,fee schedule,125.18% of custom fee schedule,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,13.74,100,,,fee schedule,Pays 100% Medicare OPPS,12.36,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,20.8,120.37,,,fee schedule,120.37% of custom fee schedule,13.74,100,,,fee schedule,Pays 100% Medicare OPPS,17.86,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,13.74,100,,,fee schedule,Pays 100% Medicare OPPS,12.36,247.5,
ANTI DNA SINGLE STRANDED,3086226,CDM,302,RC,86226,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,12.11,100,,,fee schedule,Pays 100% Medicare OPPS,12.11,100,,,fee schedule,Pays 100% Medicare OPPS,12.11,100,,,fee schedule,Pays 100% Medicare OPPS,15.74,130,,,fee schedule,Pays 130% Medicare OPPS,18.33,120.37,,,fee schedule,120.37% of custom fee schedule,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.35,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,19.06,125.18,,,fee schedule,125.18% of custom fee schedule,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,12.11,100,,,fee schedule,Pays 100% Medicare OPPS,10.89,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,18.33,120.37,,,fee schedule,120.37% of custom fee schedule,12.11,100,,,fee schedule,Pays 100% Medicare OPPS,15.74,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,12.11,100,,,fee schedule,Pays 100% Medicare OPPS,10.89,247.5,
Blood test to monitor for cytomegalovirus,3086644,CDM,302,RC,86644,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.7,130,,,fee schedule,Pays 130% Medicare OPPS,17.61,120.37,,,fee schedule,120.37% of custom fee schedule,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.67,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,18.31,125.18,,,fee schedule,125.18% of custom fee schedule,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.95,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,17.61,120.37,,,fee schedule,120.37% of custom fee schedule,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.7,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.95,247.5,
VARICELLA IgG,3086787,CDM,302,RC,86787,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.13,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,20.28,125.18,,,fee schedule,125.18% of custom fee schedule,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,247.5,
Blood test to determine infection with Hepatitis C,3086803,CDM,302,RC,86803,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,14.27,100,,,fee schedule,Pays 100% Medicare OPPS,14.27,100,,,fee schedule,Pays 100% Medicare OPPS,14.27,100,,,fee schedule,Pays 100% Medicare OPPS,18.55,130,,,fee schedule,Pays 130% Medicare OPPS,12.04,120.37,,,fee schedule,120.37% of custom fee schedule,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.55,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,12.52,125.18,,,fee schedule,125.18% of custom fee schedule,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,14.27,100,,,fee schedule,Pays 100% Medicare OPPS,12.84,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,12.04,120.37,,,fee schedule,120.37% of custom fee schedule,14.27,100,,,fee schedule,Pays 100% Medicare OPPS,18.55,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,14.27,100,,,fee schedule,Pays 100% Medicare OPPS,12.04,247.5,
Culture of the urine to determine bacterial infection,3087088,CDM,306,RC,87088,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,8.09,100,,,fee schedule,Pays 100% Medicare OPPS,8.09,100,,,fee schedule,Pays 100% Medicare OPPS,8.09,100,,,fee schedule,Pays 100% Medicare OPPS,10.51,130,,,fee schedule,Pays 130% Medicare OPPS,12.25,120.37,,,fee schedule,120.37% of custom fee schedule,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.25,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,12.74,125.18,,,fee schedule,125.18% of custom fee schedule,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,8.09,100,,,fee schedule,Pays 100% Medicare OPPS,7.28,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,12.25,120.37,,,fee schedule,120.37% of custom fee schedule,8.09,100,,,fee schedule,Pays 100% Medicare OPPS,10.51,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,8.09,100,,,fee schedule,Pays 100% Medicare OPPS,7.28,247.5,
..CLOSTRIDIUM DIFFICILE,3087324,CDM,306,RC,87493,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,37.27,100,,,fee schedule,Pays 100% Medicare OPPS,37.27,100,,,fee schedule,Pays 100% Medicare OPPS,37.27,100,,,fee schedule,Pays 100% Medicare OPPS,48.45,130,,,fee schedule,Pays 130% Medicare OPPS,56.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,38.01,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,96.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,37.27,100,,,fee schedule,Pays 100% Medicare OPPS,33.54,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,56.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,37.27,100,,,fee schedule,Pays 100% Medicare OPPS,48.45,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,37.27,100,,,fee schedule,Pays 100% Medicare OPPS,33.54,247.5,
ENTAMOEBA HISTOLYTICA ANTIBODY IGG,3087336,CDM,302,RC,86753,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.1,130,,,fee schedule,Pays 130% Medicare OPPS,18.77,120.37,,,fee schedule,120.37% of custom fee schedule,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.63,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,19.52,125.18,,,fee schedule,125.18% of custom fee schedule,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,11.15,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,18.77,120.37,,,fee schedule,120.37% of custom fee schedule,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.1,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,11.15,247.5,
NOROVIRUS STOOL LEVEL,3087449,CDM,306,RC,87449,HCPCS,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,15.57,130,,,fee schedule,Pays 130% Medicare OPPS,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.21,102,,,fee schedule,Pays 102% Medicare OPPS,247.5,90,,,percent of total billed charges,90% of total billed charges,18.88,125.18,,,fee schedule,125.18% of custom fee schedule,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,10.78,90,,,fee schedule,Pays 90% Medicare OPPS,159.5,58,,,percent of total billed charges,58% of total billed charges,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,15.57,130,,,fee schedule,Pays 130% Medicare OPPS,233.75,85,,,percent of total billed charges,85% of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,10.78,247.5,
AR/MYLEO DYE,4000030,CDM,255,RC,,,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,56.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,247.5,90,,,percent of total billed charges,90% of total billed charges,96.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,159.5,58,,,percent of total billed charges,58% of total billed charges,56.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,56.02,247.5,
ARTHRO/MYELOGRAM DYE,4000031,CDM,255,RC,,,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,56.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,247.5,90,,,percent of total billed charges,90% of total billed charges,96.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,159.5,58,,,percent of total billed charges,58% of total billed charges,56.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,56.02,247.5,
NM PERSANTINE 10M IV,4500102,CDM,255,RC,,,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,56.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,247.5,90,,,percent of total billed charges,90% of total billed charges,96.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,159.5,58,,,percent of total billed charges,58% of total billed charges,56.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,56.02,247.5,
NEEDLE GRANEE 10165,7950184,CDM,272,RC,,,Outpatient,,,275,220,,233.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,56.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,155.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,247.5,90,,,percent of total billed charges,90% of total billed charges,96.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,188.93,68.7,,,percent of total billed charges,68.7% of total billed charges,220,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,159.5,58,,,percent of total billed charges,58% of total billed charges,56.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,233.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,56.02,247.5,
SUTURE CLIP LAPRA-TY ABSORB,1570631,CDM,272,RC,,,Outpatient,,,280,224,,238,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,57.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,158.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,158.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,158.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,252,90,,,percent of total billed charges,90% of total billed charges,98,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,192.36,68.7,,,percent of total billed charges,68.7% of total billed charges,224,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,162.4,58,,,percent of total billed charges,58% of total billed charges,57.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,238,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,57.04,252,
EXCALIBUR 4.0MM X 13CM,1570820,CDM,272,RC,,,Outpatient,,,280,224,,238,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,57.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,158.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,158.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,158.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,252,90,,,percent of total billed charges,90% of total billed charges,98,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,192.36,68.7,,,percent of total billed charges,68.7% of total billed charges,224,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,162.4,58,,,percent of total billed charges,58% of total billed charges,57.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,238,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,57.04,252,
BURR OVAL 8 FLUTE 4.0MM X 13CM,1570821,CDM,272,RC,,,Outpatient,,,280,224,,238,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,57.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,158.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,158.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,158.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,252,90,,,percent of total billed charges,90% of total billed charges,98,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,192.36,68.7,,,percent of total billed charges,68.7% of total billed charges,224,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,162.4,58,,,percent of total billed charges,58% of total billed charges,57.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,238,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,57.04,252,
EXCALIBUR 5.5MM X 13CM,1570822,CDM,272,RC,,,Outpatient,,,280,224,,238,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,57.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,158.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,158.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,158.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,252,90,,,percent of total billed charges,90% of total billed charges,98,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,192.36,68.7,,,percent of total billed charges,68.7% of total billed charges,224,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,162.4,58,,,percent of total billed charges,58% of total billed charges,57.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,238,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,57.04,252,
AVC (SULFANILAMIDE) VAG CREAM,2600266,CDM,637,RC,,,Outpatient,,,280,224,,238,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,57.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,158.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,158.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,158.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,252,90,,,percent of total billed charges,90% of total billed charges,98,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,192.36,68.7,,,percent of total billed charges,68.7% of total billed charges,224,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,162.4,58,,,percent of total billed charges,58% of total billed charges,57.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,238,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,57.04,252,
**DO NOT USE**,7905651,CDM,272,RC,,,Outpatient,,,280,224,,238,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,57.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,158.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,158.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,158.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,252,90,,,percent of total billed charges,90% of total billed charges,98,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,192.36,68.7,,,percent of total billed charges,68.7% of total billed charges,224,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,162.4,58,,,percent of total billed charges,58% of total billed charges,57.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,238,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,57.04,252,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",1090774,CDM,760,RC,96374,HCPCS,Outpatient,,,285,228,,242.25,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,58.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,187.43,102,,,fee schedule,Pays 102% Medicare OPPS,256.5,90,,,percent of total billed charges,90% of total billed charges,99.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,195.8,68.7,,,percent of total billed charges,68.7% of total billed charges,228,80,,,percent of total billed charges,80 percent of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,165.38,90,,,fee schedule,Pays 90% Medicare OPPS,165.3,58,,,percent of total billed charges,58% of total billed charges,58.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,181.69,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,242.25,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,58.05,256.5,
SUTURE 2-0 VICRYL J111T,1570535,CDM,272,RC,,,Outpatient,,,285,228,,242.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,58.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,256.5,90,,,percent of total billed charges,90% of total billed charges,99.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,195.8,68.7,,,percent of total billed charges,68.7% of total billed charges,228,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,165.3,58,,,percent of total billed charges,58% of total billed charges,58.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,242.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,58.05,256.5,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",1590774,CDM,760,RC,96374,HCPCS,Outpatient,,,285,228,,242.25,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,58.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,187.43,102,,,fee schedule,Pays 102% Medicare OPPS,256.5,90,,,percent of total billed charges,90% of total billed charges,99.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,195.8,68.7,,,percent of total billed charges,68.7% of total billed charges,228,80,,,percent of total billed charges,80 percent of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,165.38,90,,,fee schedule,Pays 90% Medicare OPPS,165.3,58,,,percent of total billed charges,58% of total billed charges,58.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,181.69,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,242.25,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,58.05,256.5,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",1596374,CDM,510,RC,96374,HCPCS,Outpatient,,,285,228,,242.25,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,58.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,187.43,102,,,fee schedule,Pays 102% Medicare OPPS,256.5,90,,,percent of total billed charges,90% of total billed charges,99.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,195.8,68.7,,,percent of total billed charges,68.7% of total billed charges,228,80,,,percent of total billed charges,80 percent of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,165.38,90,,,fee schedule,Pays 90% Medicare OPPS,165.3,58,,,percent of total billed charges,58% of total billed charges,58.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,181.69,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,242.25,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,58.05,256.5,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",2090774,CDM,450,RC,96374,HCPCS,Outpatient,,,285,228,,242.25,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,58.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,187.43,102,,,fee schedule,Pays 102% Medicare OPPS,256.5,90,,,percent of total billed charges,90% of total billed charges,99.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,195.8,68.7,,,percent of total billed charges,68.7% of total billed charges,228,80,,,percent of total billed charges,80 percent of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,165.38,90,,,fee schedule,Pays 90% Medicare OPPS,165.3,58,,,percent of total billed charges,58% of total billed charges,58.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,181.69,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,242.25,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,58.05,256.5,
PRIMAXIN (IMIPENEM/CILASTATIN) 500MG,2600114,CDM,250,RC,,,Outpatient,,,285,228,,242.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,58.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,256.5,90,,,percent of total billed charges,90% of total billed charges,99.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,195.8,68.7,,,percent of total billed charges,68.7% of total billed charges,228,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,165.3,58,,,percent of total billed charges,58% of total billed charges,58.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,242.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,58.05,256.5,
RIMSO-50 (DIMETHYL SULFOXIDE) 50ML,2600159,CDM,250,RC,,,Outpatient,,,285,228,,242.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,58.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,256.5,90,,,percent of total billed charges,90% of total billed charges,99.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,195.8,68.7,,,percent of total billed charges,68.7% of total billed charges,228,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,165.3,58,,,percent of total billed charges,58% of total billed charges,58.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,242.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,58.05,256.5,
NF-TEQUIN (GATIFLOXACIN) IV : 400MG,2605053,CDM,250,RC,J1590,HCPCS,Outpatient,,,285,228,,242.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,58.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,256.5,90,,,percent of total billed charges,90% of total billed charges,99.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,195.8,68.7,,,percent of total billed charges,68.7% of total billed charges,228,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,165.3,58,,,percent of total billed charges,58% of total billed charges,58.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,242.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,58.05,256.5,
TRIGLYCERIDES BODY FLUID,3000606,CDM,300,RC,84478,HCPCS,Outpatient,,,285,228,,242.25,85,,,percent of total billed charges,85% of total billed charges,5.74,100,,,fee schedule,Pays 100% Medicare OPPS,5.74,100,,,fee schedule,Pays 100% Medicare OPPS,5.74,100,,,fee schedule,Pays 100% Medicare OPPS,7.46,130,,,fee schedule,Pays 130% Medicare OPPS,7.64,120.37,,,fee schedule,120.37% of custom fee schedule,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.85,102,,,fee schedule,Pays 102% Medicare OPPS,256.5,90,,,percent of total billed charges,90% of total billed charges,7.95,125.18,,,fee schedule,125.18% of custom fee schedule,195.8,68.7,,,percent of total billed charges,68.7% of total billed charges,228,80,,,percent of total billed charges,80 percent of total billed charges,5.74,100,,,fee schedule,Pays 100% Medicare OPPS,5.16,90,,,fee schedule,Pays 90% Medicare OPPS,165.3,58,,,percent of total billed charges,58% of total billed charges,7.64,120.37,,,fee schedule,120.37% of custom fee schedule,5.74,100,,,fee schedule,Pays 100% Medicare OPPS,7.46,130,,,fee schedule,Pays 130% Medicare OPPS,242.25,85,,,percent of total billed charges,85% of total billed charges,5.74,100,,,fee schedule,Pays 100% Medicare OPPS,5.16,256.5,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",4090774,CDM,760,RC,96374,HCPCS,Outpatient,,,285,228,,242.25,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,58.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,161.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,187.43,102,,,fee schedule,Pays 102% Medicare OPPS,256.5,90,,,percent of total billed charges,90% of total billed charges,99.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,195.8,68.7,,,percent of total billed charges,68.7% of total billed charges,228,80,,,percent of total billed charges,80 percent of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,165.38,90,,,fee schedule,Pays 90% Medicare OPPS,165.3,58,,,percent of total billed charges,58% of total billed charges,58.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,181.69,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,242.25,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,58.05,256.5,
NM TC99M MDP,4500040,CDM,636,RC,A9503,HCPCS,Both,,,285,228,,242.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,58.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,256.5,90,,,percent of total billed charges,90% of total billed charges,99.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,195.8,68.7,,,percent of total billed charges,68.7% of total billed charges,228,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,165.3,58,,,percent of total billed charges,58% of total billed charges,58.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,242.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,58.05,256.5,
VALVE TRACHEOSTOMY SPEAKING,7905590,CDM,274,RC,L8501,HCPCS,Both,,,285,228,,242.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,58.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,256.5,90,,,percent of total billed charges,90% of total billed charges,99.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,195.8,68.7,,,percent of total billed charges,68.7% of total billed charges,228,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,165.3,58,,,percent of total billed charges,58% of total billed charges,58.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,242.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,58.05,256.5,
TUBING ARTHROSCOPY PUMP,1570815,CDM,272,RC,,,Outpatient,,,290,232,,246.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,59.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,163.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,261,90,,,percent of total billed charges,90% of total billed charges,101.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,199.23,68.7,,,percent of total billed charges,68.7% of total billed charges,232,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,168.2,58,,,percent of total billed charges,58% of total billed charges,59.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,246.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,59.07,261,
CORTISPOR (NEOMYCIN/POLY/CORT) EYE SUSP,2600307,CDM,637,RC,,,Outpatient,,,290,232,,246.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,59.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,163.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,261,90,,,percent of total billed charges,90% of total billed charges,101.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,199.23,68.7,,,percent of total billed charges,68.7% of total billed charges,232,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,168.2,58,,,percent of total billed charges,58% of total billed charges,59.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,246.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,59.07,261,
RHO (D) IMMUN 300 UG DOSE,2612345,CDM,250,RC,,,Outpatient,,,290,232,,246.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,59.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,163.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,261,90,,,percent of total billed charges,90% of total billed charges,101.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,199.23,68.7,,,percent of total billed charges,68.7% of total billed charges,232,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,168.2,58,,,percent of total billed charges,58% of total billed charges,59.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,246.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,59.07,261,
"Psychotherapy, 30 min",9090832,CDM,900,RC,90832,HCPCS,Outpatient,,,290,232,,246.5,85,,,percent of total billed charges,85% of total billed charges,120.19,100,,,fee schedule,Pays 100% Medicare OPPS,120.19,100,,,fee schedule,Pays 100% Medicare OPPS,120.19,100,,,fee schedule,Pays 100% Medicare OPPS,166.6,130,,,fee schedule,Pays 130% Medicare OPPS,59.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,163.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,122.59,102,,,fee schedule,Pays 102% Medicare OPPS,261,90,,,percent of total billed charges,90% of total billed charges,101.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,199.23,68.7,,,percent of total billed charges,68.7% of total billed charges,232,80,,,percent of total billed charges,80 percent of total billed charges,120.19,100,,,fee schedule,Pays 100% Medicare OPPS,108.17,90,,,fee schedule,Pays 90% Medicare OPPS,168.2,58,,,percent of total billed charges,58% of total billed charges,59.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,128.13,100,,,fee schedule,Pays 100% Medicare OPPS,166.6,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,120.19,100,,,fee schedule,Pays 100% Medicare OPPS,59.07,261,
TAMIFLU (OSELTAMIVIR) 6MG/1ML 60ML BTL,2600085,CDM,637,RC,,,Outpatient,,,295,236,,250.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,60.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,265.5,90,,,percent of total billed charges,90% of total billed charges,103.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,202.67,68.7,,,percent of total billed charges,68.7% of total billed charges,236,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,171.1,58,,,percent of total billed charges,58% of total billed charges,60.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,250.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,60.09,265.5,
PENICILLIN G POT INJ 5MU,2602283,CDM,636,RC,,,Both,,,295,236,,250.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,60.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,265.5,90,,,percent of total billed charges,90% of total billed charges,103.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,202.67,68.7,,,percent of total billed charges,68.7% of total billed charges,236,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,171.1,58,,,percent of total billed charges,58% of total billed charges,60.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,250.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,60.09,265.5,
ROBAXIN (METHOCARBAMOL) INJ 1000MG,2602802,CDM,636,RC,J2800,HCPCS,Both,,,295,236,,250.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8.7,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,265.5,90,,,percent of total billed charges,90% of total billed charges,9.05,125.18,,,fee schedule,125.18% of custom fee schedule,202.67,68.7,,,percent of total billed charges,68.7% of total billed charges,236,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,171.1,58,,,percent of total billed charges,58% of total billed charges,8.7,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,250.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,8.7,265.5,
3RD PORPHYRIN RANDOM URINE,3000235,CDM,301,RC,84106,HCPCS,Outpatient,,,295,236,,250.75,85,,,percent of total billed charges,85% of total billed charges,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,7.56,130,,,fee schedule,Pays 130% Medicare OPPS,6.49,120.37,,,fee schedule,120.37% of custom fee schedule,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.93,102,,,fee schedule,Pays 102% Medicare OPPS,265.5,90,,,percent of total billed charges,90% of total billed charges,6.75,125.18,,,fee schedule,125.18% of custom fee schedule,202.67,68.7,,,percent of total billed charges,68.7% of total billed charges,236,80,,,percent of total billed charges,80 percent of total billed charges,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,5.23,90,,,fee schedule,Pays 90% Medicare OPPS,171.1,58,,,percent of total billed charges,58% of total billed charges,6.49,120.37,,,fee schedule,120.37% of custom fee schedule,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,7.56,130,,,fee schedule,Pays 130% Medicare OPPS,250.75,85,,,percent of total billed charges,85% of total billed charges,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,5.23,265.5,
VALIUM LEVEL,3000328,CDM,301,RC,80346,HCPCS,Outpatient,,,295,236,,250.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,28,120.37,,,fee schedule,120.37% of custom fee schedule,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,265.5,90,,,percent of total billed charges,90% of total billed charges,29.12,125.18,,,fee schedule,125.18% of custom fee schedule,202.67,68.7,,,percent of total billed charges,68.7% of total billed charges,236,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,171.1,58,,,percent of total billed charges,58% of total billed charges,28,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,250.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,28,265.5,
"ENDOMYSIAL, IgA ANTIBODY",3000349,CDM,302,RC,86255,HCPCS,Outpatient,,,295,236,,250.75,85,,,percent of total billed charges,85% of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,,,fee schedule,Pays 130% Medicare OPPS,18.25,120.37,,,fee schedule,120.37% of custom fee schedule,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.29,102,,,fee schedule,Pays 102% Medicare OPPS,265.5,90,,,percent of total billed charges,90% of total billed charges,18.98,125.18,,,fee schedule,125.18% of custom fee schedule,202.67,68.7,,,percent of total billed charges,68.7% of total billed charges,236,80,,,percent of total billed charges,80 percent of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,10.84,90,,,fee schedule,Pays 90% Medicare OPPS,171.1,58,,,percent of total billed charges,58% of total billed charges,18.25,120.37,,,fee schedule,120.37% of custom fee schedule,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,,,fee schedule,Pays 130% Medicare OPPS,250.75,85,,,percent of total billed charges,85% of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,10.84,265.5,
3RD PORPHYRIN FRACTIONATED 24 URINE,3000549,CDM,301,RC,84120,HCPCS,Outpatient,,,295,236,,250.75,85,,,percent of total billed charges,85% of total billed charges,14.71,100,,,fee schedule,Pays 100% Medicare OPPS,14.71,100,,,fee schedule,Pays 100% Medicare OPPS,14.71,100,,,fee schedule,Pays 100% Medicare OPPS,19.12,130,,,fee schedule,Pays 130% Medicare OPPS,22.27,120.37,,,fee schedule,120.37% of custom fee schedule,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15,102,,,fee schedule,Pays 102% Medicare OPPS,265.5,90,,,percent of total billed charges,90% of total billed charges,23.16,125.18,,,fee schedule,125.18% of custom fee schedule,202.67,68.7,,,percent of total billed charges,68.7% of total billed charges,236,80,,,percent of total billed charges,80 percent of total billed charges,14.71,100,,,fee schedule,Pays 100% Medicare OPPS,13.23,90,,,fee schedule,Pays 90% Medicare OPPS,171.1,58,,,percent of total billed charges,58% of total billed charges,22.27,120.37,,,fee schedule,120.37% of custom fee schedule,14.71,100,,,fee schedule,Pays 100% Medicare OPPS,19.12,130,,,fee schedule,Pays 130% Medicare OPPS,250.75,85,,,percent of total billed charges,85% of total billed charges,14.71,100,,,fee schedule,Pays 100% Medicare OPPS,13.23,265.5,
Blood test to measure a certain protein in the blood to determine heart muscle damage,3000683,CDM,301,RC,84484,HCPCS,Outpatient,,,295,236,,250.75,85,,,percent of total billed charges,85% of total billed charges,12.47,100,,,fee schedule,Pays 100% Medicare OPPS,12.47,100,,,fee schedule,Pays 100% Medicare OPPS,12.47,100,,,fee schedule,Pays 100% Medicare OPPS,16.21,130,,,fee schedule,Pays 130% Medicare OPPS,14.9,120.37,,,fee schedule,120.37% of custom fee schedule,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.71,102,,,fee schedule,Pays 102% Medicare OPPS,265.5,90,,,percent of total billed charges,90% of total billed charges,15.5,125.18,,,fee schedule,125.18% of custom fee schedule,202.67,68.7,,,percent of total billed charges,68.7% of total billed charges,236,80,,,percent of total billed charges,80 percent of total billed charges,12.47,100,,,fee schedule,Pays 100% Medicare OPPS,11.22,90,,,fee schedule,Pays 90% Medicare OPPS,171.1,58,,,percent of total billed charges,58% of total billed charges,14.9,120.37,,,fee schedule,120.37% of custom fee schedule,12.47,100,,,fee schedule,Pays 100% Medicare OPPS,16.21,130,,,fee schedule,Pays 130% Medicare OPPS,250.75,85,,,percent of total billed charges,85% of total billed charges,12.47,100,,,fee schedule,Pays 100% Medicare OPPS,11.22,265.5,
Chemical test of the blood to measure presence or concentration of a substance in the blood,3000802,CDM,301,RC,83516,HCPCS,Outpatient,,,295,236,,250.75,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.76,102,,,fee schedule,Pays 102% Medicare OPPS,265.5,90,,,percent of total billed charges,90% of total billed charges,16.84,125.18,,,fee schedule,125.18% of custom fee schedule,202.67,68.7,,,percent of total billed charges,68.7% of total billed charges,236,80,,,percent of total billed charges,80 percent of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,90,,,fee schedule,Pays 90% Medicare OPPS,171.1,58,,,percent of total billed charges,58% of total billed charges,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,250.75,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,265.5,
DESIPRAMINE LEVEL,3080160,CDM,301,RC,80335,HCPCS,Outpatient,,,295,236,,250.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.1,120.37,,,fee schedule,120.37% of custom fee schedule,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,265.5,90,,,percent of total billed charges,90% of total billed charges,28.18,125.18,,,fee schedule,125.18% of custom fee schedule,202.67,68.7,,,percent of total billed charges,68.7% of total billed charges,236,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,171.1,58,,,percent of total billed charges,58% of total billed charges,27.1,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,250.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.1,265.5,
ETHOSUXIMIDE,3080168,CDM,301,RC,80168,HCPCS,Outpatient,,,295,236,,250.75,85,,,percent of total billed charges,85% of total billed charges,16.34,100,,,fee schedule,Pays 100% Medicare OPPS,16.34,100,,,fee schedule,Pays 100% Medicare OPPS,16.34,100,,,fee schedule,Pays 100% Medicare OPPS,21.24,130,,,fee schedule,Pays 130% Medicare OPPS,24.74,120.37,,,fee schedule,120.37% of custom fee schedule,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.66,102,,,fee schedule,Pays 102% Medicare OPPS,265.5,90,,,percent of total billed charges,90% of total billed charges,25.72,125.18,,,fee schedule,125.18% of custom fee schedule,202.67,68.7,,,percent of total billed charges,68.7% of total billed charges,236,80,,,percent of total billed charges,80 percent of total billed charges,16.34,100,,,fee schedule,Pays 100% Medicare OPPS,14.7,90,,,fee schedule,Pays 90% Medicare OPPS,171.1,58,,,percent of total billed charges,58% of total billed charges,24.74,120.37,,,fee schedule,120.37% of custom fee schedule,16.34,100,,,fee schedule,Pays 100% Medicare OPPS,21.24,130,,,fee schedule,Pays 130% Medicare OPPS,250.75,85,,,percent of total billed charges,85% of total billed charges,16.34,100,,,fee schedule,Pays 100% Medicare OPPS,14.7,265.5,
Blood test to detect heart enzymes,3082553,CDM,301,RC,82553,HCPCS,Outpatient,,,295,236,,250.75,85,,,percent of total billed charges,85% of total billed charges,11.55,100,,,fee schedule,Pays 100% Medicare OPPS,11.55,100,,,fee schedule,Pays 100% Medicare OPPS,11.55,100,,,fee schedule,Pays 100% Medicare OPPS,15.01,130,,,fee schedule,Pays 130% Medicare OPPS,17.48,120.37,,,fee schedule,120.37% of custom fee schedule,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.78,102,,,fee schedule,Pays 102% Medicare OPPS,265.5,90,,,percent of total billed charges,90% of total billed charges,18.18,125.18,,,fee schedule,125.18% of custom fee schedule,202.67,68.7,,,percent of total billed charges,68.7% of total billed charges,236,80,,,percent of total billed charges,80 percent of total billed charges,11.55,100,,,fee schedule,Pays 100% Medicare OPPS,10.39,90,,,fee schedule,Pays 90% Medicare OPPS,171.1,58,,,percent of total billed charges,58% of total billed charges,17.48,120.37,,,fee schedule,120.37% of custom fee schedule,11.55,100,,,fee schedule,Pays 100% Medicare OPPS,15.01,130,,,fee schedule,Pays 130% Medicare OPPS,250.75,85,,,percent of total billed charges,85% of total billed charges,11.55,100,,,fee schedule,Pays 100% Medicare OPPS,10.39,265.5,
Chemical test of the blood to measure presence or concentration of a substance in the blood,3083520,CDM,301,RC,83516,HCPCS,Outpatient,,,295,236,,250.75,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.76,102,,,fee schedule,Pays 102% Medicare OPPS,265.5,90,,,percent of total billed charges,90% of total billed charges,16.84,125.18,,,fee schedule,125.18% of custom fee schedule,202.67,68.7,,,percent of total billed charges,68.7% of total billed charges,236,80,,,percent of total billed charges,80 percent of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,90,,,fee schedule,Pays 90% Medicare OPPS,171.1,58,,,percent of total billed charges,58% of total billed charges,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,250.75,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,265.5,
RT LACTIC ACID,3083605,CDM,301,RC,83605,HCPCS,Outpatient,,,295,236,,250.75,85,,,percent of total billed charges,85% of total billed charges,11.57,100,,,fee schedule,Pays 100% Medicare OPPS,11.57,100,,,fee schedule,Pays 100% Medicare OPPS,11.57,100,,,fee schedule,Pays 100% Medicare OPPS,15.04,130,,,fee schedule,Pays 130% Medicare OPPS,16.17,120.37,,,fee schedule,120.37% of custom fee schedule,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.8,102,,,fee schedule,Pays 102% Medicare OPPS,265.5,90,,,percent of total billed charges,90% of total billed charges,16.81,125.18,,,fee schedule,125.18% of custom fee schedule,202.67,68.7,,,percent of total billed charges,68.7% of total billed charges,236,80,,,percent of total billed charges,80 percent of total billed charges,11.57,100,,,fee schedule,Pays 100% Medicare OPPS,10.41,90,,,fee schedule,Pays 90% Medicare OPPS,171.1,58,,,percent of total billed charges,58% of total billed charges,16.17,120.37,,,fee schedule,120.37% of custom fee schedule,11.57,100,,,fee schedule,Pays 100% Medicare OPPS,15.04,130,,,fee schedule,Pays 130% Medicare OPPS,250.75,85,,,percent of total billed charges,85% of total billed charges,11.57,100,,,fee schedule,Pays 100% Medicare OPPS,10.41,265.5,
OSTEOCALCIN LEVEL,3083937,CDM,301,RC,83937,HCPCS,Outpatient,,,295,236,,250.75,85,,,percent of total billed charges,85% of total billed charges,29.85,100,,,fee schedule,Pays 100% Medicare OPPS,29.85,100,,,fee schedule,Pays 100% Medicare OPPS,29.85,100,,,fee schedule,Pays 100% Medicare OPPS,38.8,130,,,fee schedule,Pays 130% Medicare OPPS,45.19,120.37,,,fee schedule,120.37% of custom fee schedule,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,30.44,102,,,fee schedule,Pays 102% Medicare OPPS,265.5,90,,,percent of total billed charges,90% of total billed charges,46.99,125.18,,,fee schedule,125.18% of custom fee schedule,202.67,68.7,,,percent of total billed charges,68.7% of total billed charges,236,80,,,percent of total billed charges,80 percent of total billed charges,29.85,100,,,fee schedule,Pays 100% Medicare OPPS,26.86,90,,,fee schedule,Pays 90% Medicare OPPS,171.1,58,,,percent of total billed charges,58% of total billed charges,45.19,120.37,,,fee schedule,120.37% of custom fee schedule,29.85,100,,,fee schedule,Pays 100% Medicare OPPS,38.8,130,,,fee schedule,Pays 130% Medicare OPPS,250.75,85,,,percent of total billed charges,85% of total billed charges,29.85,100,,,fee schedule,Pays 100% Medicare OPPS,26.86,265.5,
Blood test to measure a certain protein in the blood to determine heart muscle damage,3084484,CDM,301,RC,84484,HCPCS,Outpatient,,,295,236,,250.75,85,,,percent of total billed charges,85% of total billed charges,12.47,100,,,fee schedule,Pays 100% Medicare OPPS,12.47,100,,,fee schedule,Pays 100% Medicare OPPS,12.47,100,,,fee schedule,Pays 100% Medicare OPPS,16.21,130,,,fee schedule,Pays 130% Medicare OPPS,14.9,120.37,,,fee schedule,120.37% of custom fee schedule,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.71,102,,,fee schedule,Pays 102% Medicare OPPS,265.5,90,,,percent of total billed charges,90% of total billed charges,15.5,125.18,,,fee schedule,125.18% of custom fee schedule,202.67,68.7,,,percent of total billed charges,68.7% of total billed charges,236,80,,,percent of total billed charges,80 percent of total billed charges,12.47,100,,,fee schedule,Pays 100% Medicare OPPS,11.22,90,,,fee schedule,Pays 90% Medicare OPPS,171.1,58,,,percent of total billed charges,58% of total billed charges,14.9,120.37,,,fee schedule,120.37% of custom fee schedule,12.47,100,,,fee schedule,Pays 100% Medicare OPPS,16.21,130,,,fee schedule,Pays 130% Medicare OPPS,250.75,85,,,percent of total billed charges,85% of total billed charges,12.47,100,,,fee schedule,Pays 100% Medicare OPPS,11.22,265.5,
Radiologic examination of the ankle with 2 views,4073600,CDM,320,RC,73600,HCPCS,Outpatient,,,295,236,,250.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,60.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,165.79,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,265.5,90,,,percent of total billed charges,90% of total billed charges,103.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,202.67,68.7,,,percent of total billed charges,68.7% of total billed charges,236,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,171.1,58,,,percent of total billed charges,58% of total billed charges,60.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,250.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,60.09,265.5,
Radiologic examination of the ankle with 2 views,4083600,CDM,320,RC,73600,HCPCS,Outpatient,,,295,236,,250.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,60.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,165.79,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,265.5,90,,,percent of total billed charges,90% of total billed charges,103.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,202.67,68.7,,,percent of total billed charges,68.7% of total billed charges,236,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,171.1,58,,,percent of total billed charges,58% of total billed charges,60.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,250.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,60.09,265.5,
Childhood test to screen for developmental disabilities,5196110,CDM,434,RC,96110,HCPCS,Outpatient,,,295,236,,250.75,85,,,percent of total billed charges,85% of total billed charges,73.75,100,,,fee schedule,Pays 100% Medicare OPPS,73.75,100,,,fee schedule,Pays 100% Medicare OPPS,73.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,60.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,265.5,90,,,percent of total billed charges,90% of total billed charges,103.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,202.67,68.7,,,percent of total billed charges,68.7% of total billed charges,236,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,265.5,90,,,fee schedule,Pays 90% Medicare OPPS,171.1,58,,,percent of total billed charges,58% of total billed charges,60.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,250.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,60.09,265.5,
NEEDLE SCLERotherAPY,7950187,CDM,278,RC,,,Both,,,295,236,,250.75,85,,,percent of total billed charges,85% of total billed charges,73.75,100,,,fee schedule,Pays 100% Medicare OPPS,73.75,100,,,fee schedule,Pays 100% Medicare OPPS,73.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,60.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,265.5,90,,,percent of total billed charges,90% of total billed charges,103.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,202.67,68.7,,,percent of total billed charges,68.7% of total billed charges,236,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,265.5,90,,,fee schedule,Pays 90% Medicare OPPS,171.1,58,,,percent of total billed charges,58% of total billed charges,60.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,250.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,60.09,265.5,
MARKER BREAST TISSUE SENOMARK ULTRACOR,7950223,CDM,272,RC,,,Outpatient,,,295,236,,250.75,85,,,percent of total billed charges,85% of total billed charges,73.75,100,,,fee schedule,Pays 100% Medicare OPPS,73.75,100,,,fee schedule,Pays 100% Medicare OPPS,73.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,60.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,265.5,90,,,percent of total billed charges,90% of total billed charges,103.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,202.67,68.7,,,percent of total billed charges,68.7% of total billed charges,236,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,265.5,90,,,fee schedule,Pays 90% Medicare OPPS,171.1,58,,,percent of total billed charges,58% of total billed charges,60.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,250.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,60.09,265.5,
LINEAR CUTTER RELOAD TCR75,7950249,CDM,272,RC,,,Outpatient,,,295,236,,250.75,85,,,percent of total billed charges,85% of total billed charges,73.75,100,,,fee schedule,Pays 100% Medicare OPPS,73.75,100,,,fee schedule,Pays 100% Medicare OPPS,73.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,60.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,166.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,265.5,90,,,percent of total billed charges,90% of total billed charges,103.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,202.67,68.7,,,percent of total billed charges,68.7% of total billed charges,236,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,265.5,90,,,fee schedule,Pays 90% Medicare OPPS,171.1,58,,,percent of total billed charges,58% of total billed charges,60.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,250.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,60.09,265.5,
FETAL MONITOR,408020,CDM,720,RC,59050,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,75,100,,,fee schedule,Pays 100% Medicare OPPS,75,100,,,fee schedule,Pays 100% Medicare OPPS,75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,270,90,,,percent of total billed charges,90% of total billed charges,105,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,270,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,255,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,61.11,270,
FETAL MONITOR,2059050,CDM,450,RC,59050,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,75,100,,,fee schedule,Pays 100% Medicare OPPS,75,100,,,fee schedule,Pays 100% Medicare OPPS,75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,270,90,,,percent of total billed charges,90% of total billed charges,105,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,270,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,255,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,61.11,270,
IM INJECT ANESTHETIC AGENT FACIAL NERVE,2064402,CDM,761,RC,64402,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,75,100,,,fee schedule,Pays 100% Medicare OPPS,75,100,,,fee schedule,Pays 100% Medicare OPPS,75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,270,90,,,percent of total billed charges,90% of total billed charges,105,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,270,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,255,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,61.11,270,
CEFZIL (CEFPROZIL) 250MG/5ML SUSP 50ML,2602324,CDM,637,RC,,,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,75,100,,,fee schedule,Pays 100% Medicare OPPS,75,100,,,fee schedule,Pays 100% Medicare OPPS,75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,270,90,,,percent of total billed charges,90% of total billed charges,105,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,270,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,255,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,61.11,270,
AVELOX (MOXIFLOXACIN) IV 400MG,2605131,CDM,636,RC,J2280,HCPCS,Both,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,75,100,,,fee schedule,Pays 100% Medicare OPPS,75,100,,,fee schedule,Pays 100% Medicare OPPS,75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,270,90,,,percent of total billed charges,90% of total billed charges,105,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,270,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,255,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,61.11,270,
"AMYLASE, FLUID",3000006,CDM,301,RC,82150,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,6.48,100,,,fee schedule,Pays 100% Medicare OPPS,6.48,100,,,fee schedule,Pays 100% Medicare OPPS,6.48,100,,,fee schedule,Pays 100% Medicare OPPS,8.42,130,,,fee schedule,Pays 130% Medicare OPPS,9.81,120.37,,,fee schedule,120.37% of custom fee schedule,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.6,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,10.2,125.18,,,fee schedule,125.18% of custom fee schedule,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,6.48,100,,,fee schedule,Pays 100% Medicare OPPS,5.83,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,9.81,120.37,,,fee schedule,120.37% of custom fee schedule,6.48,100,,,fee schedule,Pays 100% Medicare OPPS,8.42,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,6.48,100,,,fee schedule,Pays 100% Medicare OPPS,5.83,270,
"AMYLASE, SERUM",3000007,CDM,301,RC,82150,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,6.48,100,,,fee schedule,Pays 100% Medicare OPPS,6.48,100,,,fee schedule,Pays 100% Medicare OPPS,6.48,100,,,fee schedule,Pays 100% Medicare OPPS,8.42,130,,,fee schedule,Pays 130% Medicare OPPS,9.81,120.37,,,fee schedule,120.37% of custom fee schedule,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.6,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,10.2,125.18,,,fee schedule,125.18% of custom fee schedule,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,6.48,100,,,fee schedule,Pays 100% Medicare OPPS,5.83,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,9.81,120.37,,,fee schedule,120.37% of custom fee schedule,6.48,100,,,fee schedule,Pays 100% Medicare OPPS,8.42,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,6.48,100,,,fee schedule,Pays 100% Medicare OPPS,5.83,270,
CRYPTOCOCCUS ANTIGEN(CSF),3000063,CDM,302,RC,87449,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,15.57,130,,,fee schedule,Pays 130% Medicare OPPS,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.21,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,18.88,125.18,,,fee schedule,125.18% of custom fee schedule,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,10.78,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,15.57,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,10.78,270,
.EHRLICH.TIT IgM(CHAFF/EQU,3000095,CDM,302,RC,86666,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,13.23,130,,,fee schedule,Pays 130% Medicare OPPS,15.41,120.37,,,fee schedule,120.37% of custom fee schedule,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,10.38,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,16.02,125.18,,,fee schedule,125.18% of custom fee schedule,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,9.16,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,15.41,120.37,,,fee schedule,120.37% of custom fee schedule,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,13.23,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,9.16,270,
FACTOR V LEIDEN,3000110,CDM,300,RC,81241,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,73.37,100,,,fee schedule,Pays 100% Medicare OPPS,73.37,100,,,fee schedule,Pays 100% Medicare OPPS,73.37,100,,,fee schedule,Pays 100% Medicare OPPS,95.38,130,,,fee schedule,Pays 130% Medicare OPPS,48.15,120.37,,,fee schedule,120.37% of custom fee schedule,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.83,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,50.07,125.18,,,fee schedule,125.18% of custom fee schedule,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,73.37,100,,,fee schedule,Pays 100% Medicare OPPS,66.03,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,48.15,120.37,,,fee schedule,120.37% of custom fee schedule,73.37,100,,,fee schedule,Pays 100% Medicare OPPS,95.38,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,73.37,100,,,fee schedule,Pays 100% Medicare OPPS,48.15,270,
PROTHROMBIN MUTATION,3000243,CDM,300,RC,81240,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,65.69,100,,,fee schedule,Pays 100% Medicare OPPS,65.69,100,,,fee schedule,Pays 100% Medicare OPPS,65.69,100,,,fee schedule,Pays 100% Medicare OPPS,85.39,130,,,fee schedule,Pays 130% Medicare OPPS,48.15,120.37,,,fee schedule,120.37% of custom fee schedule,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,67,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,50.07,125.18,,,fee schedule,125.18% of custom fee schedule,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,65.69,100,,,fee schedule,Pays 100% Medicare OPPS,59.12,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,48.15,120.37,,,fee schedule,120.37% of custom fee schedule,65.69,100,,,fee schedule,Pays 100% Medicare OPPS,85.39,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,65.69,100,,,fee schedule,Pays 100% Medicare OPPS,48.15,270,
STONE ANALYSIS,3000291,CDM,301,RC,82365,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,12.9,100,,,fee schedule,Pays 100% Medicare OPPS,12.9,100,,,fee schedule,Pays 100% Medicare OPPS,12.9,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,130,,,fee schedule,Pays 130% Medicare OPPS,19.51,120.37,,,fee schedule,120.37% of custom fee schedule,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.15,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,20.29,125.18,,,fee schedule,125.18% of custom fee schedule,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,12.9,100,,,fee schedule,Pays 100% Medicare OPPS,11.61,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,19.51,120.37,,,fee schedule,120.37% of custom fee schedule,12.9,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,12.9,100,,,fee schedule,Pays 100% Medicare OPPS,11.61,270,
"LIPASE, PERITONEAL FLUID",3000554,CDM,301,RC,83690,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,6.89,100,,,fee schedule,Pays 100% Medicare OPPS,6.89,100,,,fee schedule,Pays 100% Medicare OPPS,6.89,100,,,fee schedule,Pays 100% Medicare OPPS,8.95,130,,,fee schedule,Pays 130% Medicare OPPS,10.42,120.37,,,fee schedule,120.37% of custom fee schedule,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,7.02,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,10.84,125.18,,,fee schedule,125.18% of custom fee schedule,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,6.89,100,,,fee schedule,Pays 100% Medicare OPPS,6.2,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,10.42,120.37,,,fee schedule,120.37% of custom fee schedule,6.89,100,,,fee schedule,Pays 100% Medicare OPPS,8.95,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,6.89,100,,,fee schedule,Pays 100% Medicare OPPS,6.2,270,
PROTEIN ELEC (24H URINE),3000572,CDM,301,RC,84165,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,13.96,130,,,fee schedule,Pays 130% Medicare OPPS,16.26,120.37,,,fee schedule,120.37% of custom fee schedule,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,10.95,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,16.91,125.18,,,fee schedule,125.18% of custom fee schedule,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,9.66,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,16.26,120.37,,,fee schedule,120.37% of custom fee schedule,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,13.96,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,10.74,100,,,fee schedule,Pays 100% Medicare OPPS,9.66,270,
THEOPHYLLINE LEVEL,3080198,CDM,301,RC,80198,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,14.14,100,,,fee schedule,Pays 100% Medicare OPPS,14.14,100,,,fee schedule,Pays 100% Medicare OPPS,14.14,100,,,fee schedule,Pays 100% Medicare OPPS,18.38,130,,,fee schedule,Pays 130% Medicare OPPS,21.41,120.37,,,fee schedule,120.37% of custom fee schedule,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.42,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,22.27,125.18,,,fee schedule,125.18% of custom fee schedule,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,14.14,100,,,fee schedule,Pays 100% Medicare OPPS,12.72,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,21.41,120.37,,,fee schedule,120.37% of custom fee schedule,14.14,100,,,fee schedule,Pays 100% Medicare OPPS,18.38,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,14.14,100,,,fee schedule,Pays 100% Medicare OPPS,12.72,270,
Testing for presence of drug,3082101,CDM,301,RC,80307,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,80.78,130,,,fee schedule,Pays 130% Medicare OPPS,73.62,120.37,,,fee schedule,120.37% of custom fee schedule,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,63.38,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,76.56,125.18,,,fee schedule,125.18% of custom fee schedule,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,55.92,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,73.62,120.37,,,fee schedule,120.37% of custom fee schedule,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,80.78,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,55.92,270,
3RD ALPHA-1-ANTITRYPSIN,3082103,CDM,301,RC,82104,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,14.46,100,,,fee schedule,Pays 100% Medicare OPPS,14.46,100,,,fee schedule,Pays 100% Medicare OPPS,14.46,100,,,fee schedule,Pays 100% Medicare OPPS,18.79,130,,,fee schedule,Pays 130% Medicare OPPS,21.88,120.37,,,fee schedule,120.37% of custom fee schedule,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.74,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,22.76,125.18,,,fee schedule,125.18% of custom fee schedule,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,14.46,100,,,fee schedule,Pays 100% Medicare OPPS,13.01,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,21.88,120.37,,,fee schedule,120.37% of custom fee schedule,14.46,100,,,fee schedule,Pays 100% Medicare OPPS,18.79,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,14.46,100,,,fee schedule,Pays 100% Medicare OPPS,13.01,270,
.ALPHA-1 ANTITRYPSIN PHENO,3082104,CDM,300,RC,82104,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,14.46,100,,,fee schedule,Pays 100% Medicare OPPS,14.46,100,,,fee schedule,Pays 100% Medicare OPPS,14.46,100,,,fee schedule,Pays 100% Medicare OPPS,18.79,130,,,fee schedule,Pays 130% Medicare OPPS,21.88,120.37,,,fee schedule,120.37% of custom fee schedule,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.74,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,22.76,125.18,,,fee schedule,125.18% of custom fee schedule,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,14.46,100,,,fee schedule,Pays 100% Medicare OPPS,13.01,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,21.88,120.37,,,fee schedule,120.37% of custom fee schedule,14.46,100,,,fee schedule,Pays 100% Medicare OPPS,18.79,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,14.46,100,,,fee schedule,Pays 100% Medicare OPPS,13.01,270,
"BARBITURATES QUANTITATIVE,SERUM",3082205,CDM,301,RC,,,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,270,90,,,percent of total billed charges,90% of total billed charges,105,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,174,58,,,percent of total billed charges,58% of total billed charges,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,255,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,61.11,270,
"5 HIAA, UA",3083497,CDM,301,RC,83497,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,12.9,100,,,fee schedule,Pays 100% Medicare OPPS,12.9,100,,,fee schedule,Pays 100% Medicare OPPS,12.9,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,130,,,fee schedule,Pays 130% Medicare OPPS,19.51,120.37,,,fee schedule,120.37% of custom fee schedule,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.15,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,20.29,125.18,,,fee schedule,125.18% of custom fee schedule,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,12.9,100,,,fee schedule,Pays 100% Medicare OPPS,11.61,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,19.51,120.37,,,fee schedule,120.37% of custom fee schedule,12.9,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,12.9,100,,,fee schedule,Pays 100% Medicare OPPS,11.61,270,
LIPASE LEVEL,3083690,CDM,301,RC,83690,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,6.89,100,,,fee schedule,Pays 100% Medicare OPPS,6.89,100,,,fee schedule,Pays 100% Medicare OPPS,6.89,100,,,fee schedule,Pays 100% Medicare OPPS,8.95,130,,,fee schedule,Pays 130% Medicare OPPS,10.42,120.37,,,fee schedule,120.37% of custom fee schedule,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,7.02,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,10.84,125.18,,,fee schedule,125.18% of custom fee schedule,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,6.89,100,,,fee schedule,Pays 100% Medicare OPPS,6.2,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,10.42,120.37,,,fee schedule,120.37% of custom fee schedule,6.89,100,,,fee schedule,Pays 100% Medicare OPPS,8.95,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,6.89,100,,,fee schedule,Pays 100% Medicare OPPS,6.2,270,
ANTITHROMBIN III ANTIGEN,3085301,CDM,305,RC,85301,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,10.81,100,,,fee schedule,Pays 100% Medicare OPPS,10.81,100,,,fee schedule,Pays 100% Medicare OPPS,10.81,100,,,fee schedule,Pays 100% Medicare OPPS,14.05,130,,,fee schedule,Pays 130% Medicare OPPS,16.37,120.37,,,fee schedule,120.37% of custom fee schedule,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.02,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,17.02,125.18,,,fee schedule,125.18% of custom fee schedule,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,10.81,100,,,fee schedule,Pays 100% Medicare OPPS,9.72,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,16.37,120.37,,,fee schedule,120.37% of custom fee schedule,10.81,100,,,fee schedule,Pays 100% Medicare OPPS,14.05,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,10.81,100,,,fee schedule,Pays 100% Medicare OPPS,9.72,270,
.EHRLICH.TIT IgG(CHAFF/EQU,3086666,CDM,302,RC,86666,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,13.23,130,,,fee schedule,Pays 130% Medicare OPPS,15.41,120.37,,,fee schedule,120.37% of custom fee schedule,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,10.38,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,16.02,125.18,,,fee schedule,125.18% of custom fee schedule,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,9.16,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,15.41,120.37,,,fee schedule,120.37% of custom fee schedule,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,13.23,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,9.16,270,
LEPTOSPIRA URINE PCR,3086720,CDM,302,RC,87798,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,,,fee schedule,Pays 130% Medicare OPPS,29.7,120.37,,,fee schedule,120.37% of custom fee schedule,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,35.79,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,30.88,125.18,,,fee schedule,125.18% of custom fee schedule,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,31.58,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,29.7,120.37,,,fee schedule,120.37% of custom fee schedule,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,29.7,270,
AMOEBIC ANTIBODIES,3086753,CDM,302,RC,86753,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.1,130,,,fee schedule,Pays 130% Medicare OPPS,18.77,120.37,,,fee schedule,120.37% of custom fee schedule,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.63,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,19.52,125.18,,,fee schedule,125.18% of custom fee schedule,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,11.15,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,18.77,120.37,,,fee schedule,120.37% of custom fee schedule,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.1,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,11.15,270,
Blood test to screen for bacteria in the blood,3087040,CDM,306,RC,87040,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,10.32,100,,,fee schedule,Pays 100% Medicare OPPS,10.32,100,,,fee schedule,Pays 100% Medicare OPPS,10.32,100,,,fee schedule,Pays 100% Medicare OPPS,13.41,130,,,fee schedule,Pays 130% Medicare OPPS,15.62,120.37,,,fee schedule,120.37% of custom fee schedule,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,10.52,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,16.25,125.18,,,fee schedule,125.18% of custom fee schedule,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,10.32,100,,,fee schedule,Pays 100% Medicare OPPS,9.28,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,15.62,120.37,,,fee schedule,120.37% of custom fee schedule,10.32,100,,,fee schedule,Pays 100% Medicare OPPS,13.41,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,10.32,100,,,fee schedule,Pays 100% Medicare OPPS,9.28,270,
CULTURE CYTOMEGALOVIRUS,3087252,CDM,306,RC,87252,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,33.89,130,,,fee schedule,Pays 130% Medicare OPPS,33.46,120.37,,,fee schedule,120.37% of custom fee schedule,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,26.59,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,34.8,125.18,,,fee schedule,125.18% of custom fee schedule,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,23.46,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,33.46,120.37,,,fee schedule,120.37% of custom fee schedule,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,33.89,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,23.46,270,
GIEMSA STAIN,3088313,CDM,312,RC,87207,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,5.99,100,,,fee schedule,Pays 100% Medicare OPPS,5.99,100,,,fee schedule,Pays 100% Medicare OPPS,5.99,100,,,fee schedule,Pays 100% Medicare OPPS,7.78,130,,,fee schedule,Pays 130% Medicare OPPS,9.06,120.37,,,fee schedule,120.37% of custom fee schedule,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.1,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,9.43,125.18,,,fee schedule,125.18% of custom fee schedule,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,5.99,100,,,fee schedule,Pays 100% Medicare OPPS,5.39,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,9.06,120.37,,,fee schedule,120.37% of custom fee schedule,5.99,100,,,fee schedule,Pays 100% Medicare OPPS,7.78,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,5.99,100,,,fee schedule,Pays 100% Medicare OPPS,5.39,270,
IM INJECTION FEE,3090772,CDM,510,RC,96372,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,56.8,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,105,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,50.12,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,59.34,100,,,fee schedule,Pays 100% Medicare OPPS,77.14,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,55.69,100,,,fee schedule,Pays 100% Medicare OPPS,50.12,270,
FETAL MONITOR,4059050,CDM,720,RC,59050,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,270,90,,,percent of total billed charges,90% of total billed charges,105,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,174,58,,,percent of total billed charges,58% of total billed charges,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,255,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,61.11,270,
XR EXTRA VIEWS,4070150,CDM,320,RC,76499,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,168.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,105,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,61.11,270,
Radiologic examination of the finger(s),4073140,CDM,320,RC,73140,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,168.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,105,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,61.11,270,
Radiologic examination of the toe(s),4073660,CDM,320,RC,73660,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,168.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,105,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,61.11,270,
Radiologic examination of the finger(s),4083140,CDM,320,RC,73140,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,168.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,105,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,61.11,270,
Radiologic examination of the toe(s),4083660,CDM,320,RC,73660,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,168.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,270,90,,,percent of total billed charges,90% of total billed charges,105,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,174,58,,,percent of total billed charges,58% of total billed charges,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,255,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,61.11,270,
INJECTION FOR MYELOGRAPHY,4262284,CDM,352,RC,62284,HCPCS,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,168.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,270,90,,,percent of total billed charges,90% of total billed charges,105,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,174,58,,,percent of total billed charges,58% of total billed charges,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,255,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,61.11,270,
VACUUM CUP 003CB,7905537,CDM,270,RC,,,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,270,90,,,percent of total billed charges,90% of total billed charges,105,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,174,58,,,percent of total billed charges,58% of total billed charges,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,255,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,61.11,270,
ENDOPATH BABCOCK GRASPERS 5BB,7950152,CDM,272,RC,,,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,270,90,,,percent of total billed charges,90% of total billed charges,105,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,174,58,,,percent of total billed charges,58% of total billed charges,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,255,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,61.11,270,
LINEAR CUTTER RELOAD THICK 75MM TRT75,7950254,CDM,272,RC,,,Outpatient,,,300,240,,255,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,169.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,270,90,,,percent of total billed charges,90% of total billed charges,105,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,206.1,68.7,,,percent of total billed charges,68.7% of total billed charges,240,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,174,58,,,percent of total billed charges,58% of total billed charges,61.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,255,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,61.11,270,
MOLECULAR DGN AMP (C FG X,3000201,CDM,301,RC,81223,HCPCS,Outpatient,,,305,244,,259.25,85,,,percent of total billed charges,85% of total billed charges,499,100,,,fee schedule,Pays 100% Medicare OPPS,499,100,,,fee schedule,Pays 100% Medicare OPPS,499,100,,,fee schedule,Pays 100% Medicare OPPS,648.7,130,,,fee schedule,Pays 130% Medicare OPPS,1155.55,120.37,,,fee schedule,120.37% of custom fee schedule,172.33,56.5,,,percent of total billed charges,56.5 percent of total billed charges,172.33,56.5,,,percent of total billed charges,56.5 percent of total billed charges,172.33,56.5,,,percent of total billed charges,56.5 percent of total billed charges,172.33,56.5,,,percent of total billed charges,56.5 percent of total billed charges,508.98,102,,,fee schedule,Pays 102% Medicare OPPS,274.5,90,,,percent of total billed charges,90% of total billed charges,1201.73,125.18,,,fee schedule,125.18% of custom fee schedule,209.54,68.7,,,percent of total billed charges,68.7% of total billed charges,244,80,,,percent of total billed charges,80 percent of total billed charges,499,100,,,fee schedule,Pays 100% Medicare OPPS,449.1,90,,,fee schedule,Pays 90% Medicare OPPS,176.9,58,,,percent of total billed charges,58% of total billed charges,1155.55,120.37,,,fee schedule,120.37% of custom fee schedule,499,100,,,fee schedule,Pays 100% Medicare OPPS,648.7,130,,,fee schedule,Pays 130% Medicare OPPS,259.25,85,,,percent of total billed charges,85% of total billed charges,499,100,,,fee schedule,Pays 100% Medicare OPPS,172.33,1201.73,
SPLINT APP FINGER,2029130,CDM,450,RC,29130,HCPCS,Outpatient,,,310,248,,263.5,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,63.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,279,90,,,percent of total billed charges,90% of total billed charges,108.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,212.97,68.7,,,percent of total billed charges,68.7% of total billed charges,248,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,179.8,58,,,percent of total billed charges,58% of total billed charges,63.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,263.5,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,63.15,279,
"New patient office of other outpatient visit, typically 60 min",2099205,CDM,450,RC,99205,HCPCS,Outpatient,,,310,248,,263.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,279,90,,,percent of total billed charges,90% of total billed charges,108.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,212.97,68.7,,,percent of total billed charges,68.7% of total billed charges,248,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,179.8,58,,,percent of total billed charges,58% of total billed charges,63.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,263.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,63.15,279,
Test of body fluid other than blood to assess for bacteria,3000070,CDM,306,RC,87070,HCPCS,Outpatient,,,310,248,,263.5,85,,,percent of total billed charges,85% of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.2,130,,,fee schedule,Pays 130% Medicare OPPS,13.04,120.37,,,fee schedule,120.37% of custom fee schedule,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.79,102,,,fee schedule,Pays 102% Medicare OPPS,279,90,,,percent of total billed charges,90% of total billed charges,13.56,125.18,,,fee schedule,125.18% of custom fee schedule,212.97,68.7,,,percent of total billed charges,68.7% of total billed charges,248,80,,,percent of total billed charges,80 percent of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,7.75,90,,,fee schedule,Pays 90% Medicare OPPS,179.8,58,,,percent of total billed charges,58% of total billed charges,13.04,120.37,,,fee schedule,120.37% of custom fee schedule,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.2,130,,,fee schedule,Pays 130% Medicare OPPS,263.5,85,,,percent of total billed charges,85% of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,7.75,279,
Test of body fluid other than blood to assess for bacteria,3000071,CDM,306,RC,87070,HCPCS,Outpatient,,,310,248,,263.5,85,,,percent of total billed charges,85% of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.2,130,,,fee schedule,Pays 130% Medicare OPPS,13.04,120.37,,,fee schedule,120.37% of custom fee schedule,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.79,102,,,fee schedule,Pays 102% Medicare OPPS,279,90,,,percent of total billed charges,90% of total billed charges,13.56,125.18,,,fee schedule,125.18% of custom fee schedule,212.97,68.7,,,percent of total billed charges,68.7% of total billed charges,248,80,,,percent of total billed charges,80 percent of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,7.75,90,,,fee schedule,Pays 90% Medicare OPPS,179.8,58,,,percent of total billed charges,58% of total billed charges,13.04,120.37,,,fee schedule,120.37% of custom fee schedule,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.2,130,,,fee schedule,Pays 130% Medicare OPPS,263.5,85,,,percent of total billed charges,85% of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,7.75,279,
Test of body fluid other than blood to assess for bacteria,3000073,CDM,306,RC,87070,HCPCS,Outpatient,,,310,248,,263.5,85,,,percent of total billed charges,85% of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.2,130,,,fee schedule,Pays 130% Medicare OPPS,13.04,120.37,,,fee schedule,120.37% of custom fee schedule,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.79,102,,,fee schedule,Pays 102% Medicare OPPS,279,90,,,percent of total billed charges,90% of total billed charges,13.56,125.18,,,fee schedule,125.18% of custom fee schedule,212.97,68.7,,,percent of total billed charges,68.7% of total billed charges,248,80,,,percent of total billed charges,80 percent of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,7.75,90,,,fee schedule,Pays 90% Medicare OPPS,179.8,58,,,percent of total billed charges,58% of total billed charges,13.04,120.37,,,fee schedule,120.37% of custom fee schedule,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.2,130,,,fee schedule,Pays 130% Medicare OPPS,263.5,85,,,percent of total billed charges,85% of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,7.75,279,
"METHOTREXATE, SERUM",3000197,CDM,301,RC,80299,HCPCS,Outpatient,,,310,248,,263.5,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.01,102,,,fee schedule,Pays 102% Medicare OPPS,279,90,,,percent of total billed charges,90% of total billed charges,18.95,125.18,,,fee schedule,125.18% of custom fee schedule,212.97,68.7,,,percent of total billed charges,68.7% of total billed charges,248,80,,,percent of total billed charges,80 percent of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,90,,,fee schedule,Pays 90% Medicare OPPS,179.8,58,,,percent of total billed charges,58% of total billed charges,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,263.5,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,279,
VON WILLEBRAND ANTIGEN,3000332,CDM,300,RC,85245,HCPCS,Outpatient,,,310,248,,263.5,85,,,percent of total billed charges,85% of total billed charges,22.94,100,,,fee schedule,Pays 100% Medicare OPPS,22.94,100,,,fee schedule,Pays 100% Medicare OPPS,22.94,100,,,fee schedule,Pays 100% Medicare OPPS,29.82,130,,,fee schedule,Pays 130% Medicare OPPS,34.73,120.37,,,fee schedule,120.37% of custom fee schedule,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,23.39,102,,,fee schedule,Pays 102% Medicare OPPS,279,90,,,percent of total billed charges,90% of total billed charges,36.11,125.18,,,fee schedule,125.18% of custom fee schedule,212.97,68.7,,,percent of total billed charges,68.7% of total billed charges,248,80,,,percent of total billed charges,80 percent of total billed charges,22.94,100,,,fee schedule,Pays 100% Medicare OPPS,20.64,90,,,fee schedule,Pays 90% Medicare OPPS,179.8,58,,,percent of total billed charges,58% of total billed charges,34.73,120.37,,,fee schedule,120.37% of custom fee schedule,22.94,100,,,fee schedule,Pays 100% Medicare OPPS,29.82,130,,,fee schedule,Pays 130% Medicare OPPS,263.5,85,,,percent of total billed charges,85% of total billed charges,22.94,100,,,fee schedule,Pays 100% Medicare OPPS,20.64,279,
Test of body fluid other than blood to assess for bacteria,3000390,CDM,306,RC,87070,HCPCS,Outpatient,,,310,248,,263.5,85,,,percent of total billed charges,85% of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.2,130,,,fee schedule,Pays 130% Medicare OPPS,13.04,120.37,,,fee schedule,120.37% of custom fee schedule,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.79,102,,,fee schedule,Pays 102% Medicare OPPS,279,90,,,percent of total billed charges,90% of total billed charges,13.56,125.18,,,fee schedule,125.18% of custom fee schedule,212.97,68.7,,,percent of total billed charges,68.7% of total billed charges,248,80,,,percent of total billed charges,80 percent of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,7.75,90,,,fee schedule,Pays 90% Medicare OPPS,179.8,58,,,percent of total billed charges,58% of total billed charges,13.04,120.37,,,fee schedule,120.37% of custom fee schedule,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.2,130,,,fee schedule,Pays 130% Medicare OPPS,263.5,85,,,percent of total billed charges,85% of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,7.75,279,
Test of body fluid other than blood to assess for bacteria,3000391,CDM,306,RC,87070,HCPCS,Outpatient,,,310,248,,263.5,85,,,percent of total billed charges,85% of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.2,130,,,fee schedule,Pays 130% Medicare OPPS,13.04,120.37,,,fee schedule,120.37% of custom fee schedule,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.79,102,,,fee schedule,Pays 102% Medicare OPPS,279,90,,,percent of total billed charges,90% of total billed charges,13.56,125.18,,,fee schedule,125.18% of custom fee schedule,212.97,68.7,,,percent of total billed charges,68.7% of total billed charges,248,80,,,percent of total billed charges,80 percent of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,7.75,90,,,fee schedule,Pays 90% Medicare OPPS,179.8,58,,,percent of total billed charges,58% of total billed charges,13.04,120.37,,,fee schedule,120.37% of custom fee schedule,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.2,130,,,fee schedule,Pays 130% Medicare OPPS,263.5,85,,,percent of total billed charges,85% of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,7.75,279,
Test of body fluid other than blood to assess for bacteria,3000565,CDM,306,RC,87070,HCPCS,Outpatient,,,310,248,,263.5,85,,,percent of total billed charges,85% of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.2,130,,,fee schedule,Pays 130% Medicare OPPS,13.04,120.37,,,fee schedule,120.37% of custom fee schedule,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.79,102,,,fee schedule,Pays 102% Medicare OPPS,279,90,,,percent of total billed charges,90% of total billed charges,13.56,125.18,,,fee schedule,125.18% of custom fee schedule,212.97,68.7,,,percent of total billed charges,68.7% of total billed charges,248,80,,,percent of total billed charges,80 percent of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,7.75,90,,,fee schedule,Pays 90% Medicare OPPS,179.8,58,,,percent of total billed charges,58% of total billed charges,13.04,120.37,,,fee schedule,120.37% of custom fee schedule,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.2,130,,,fee schedule,Pays 130% Medicare OPPS,263.5,85,,,percent of total billed charges,85% of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,7.75,279,
Test of body fluid other than blood to assess for bacteria,3000566,CDM,306,RC,87070,HCPCS,Outpatient,,,310,248,,263.5,85,,,percent of total billed charges,85% of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.2,130,,,fee schedule,Pays 130% Medicare OPPS,13.04,120.37,,,fee schedule,120.37% of custom fee schedule,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.79,102,,,fee schedule,Pays 102% Medicare OPPS,279,90,,,percent of total billed charges,90% of total billed charges,13.56,125.18,,,fee schedule,125.18% of custom fee schedule,212.97,68.7,,,percent of total billed charges,68.7% of total billed charges,248,80,,,percent of total billed charges,80 percent of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,7.75,90,,,fee schedule,Pays 90% Medicare OPPS,179.8,58,,,percent of total billed charges,58% of total billed charges,13.04,120.37,,,fee schedule,120.37% of custom fee schedule,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.2,130,,,fee schedule,Pays 130% Medicare OPPS,263.5,85,,,percent of total billed charges,85% of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,7.75,279,
Test of body fluid other than blood to assess for bacteria,3000708,CDM,306,RC,87070,HCPCS,Outpatient,,,310,248,,263.5,85,,,percent of total billed charges,85% of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.2,130,,,fee schedule,Pays 130% Medicare OPPS,13.04,120.37,,,fee schedule,120.37% of custom fee schedule,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.79,102,,,fee schedule,Pays 102% Medicare OPPS,279,90,,,percent of total billed charges,90% of total billed charges,13.56,125.18,,,fee schedule,125.18% of custom fee schedule,212.97,68.7,,,percent of total billed charges,68.7% of total billed charges,248,80,,,percent of total billed charges,80 percent of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,7.75,90,,,fee schedule,Pays 90% Medicare OPPS,179.8,58,,,percent of total billed charges,58% of total billed charges,13.04,120.37,,,fee schedule,120.37% of custom fee schedule,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.2,130,,,fee schedule,Pays 130% Medicare OPPS,263.5,85,,,percent of total billed charges,85% of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,7.75,279,
RBC FOLATE,3082747,CDM,301,RC,85014,HCPCS,Outpatient,,,310,248,,263.5,85,,,percent of total billed charges,85% of total billed charges,2.37,100,,,fee schedule,Pays 100% Medicare OPPS,2.37,100,,,fee schedule,Pays 100% Medicare OPPS,2.37,100,,,fee schedule,Pays 100% Medicare OPPS,3.08,130,,,fee schedule,Pays 130% Medicare OPPS,3.59,120.37,,,fee schedule,120.37% of custom fee schedule,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2.41,102,,,fee schedule,Pays 102% Medicare OPPS,279,90,,,percent of total billed charges,90% of total billed charges,3.73,125.18,,,fee schedule,125.18% of custom fee schedule,212.97,68.7,,,percent of total billed charges,68.7% of total billed charges,248,80,,,percent of total billed charges,80 percent of total billed charges,2.37,100,,,fee schedule,Pays 100% Medicare OPPS,2.13,90,,,fee schedule,Pays 90% Medicare OPPS,179.8,58,,,percent of total billed charges,58% of total billed charges,3.59,120.37,,,fee schedule,120.37% of custom fee schedule,2.37,100,,,fee schedule,Pays 100% Medicare OPPS,3.08,130,,,fee schedule,Pays 130% Medicare OPPS,263.5,85,,,percent of total billed charges,85% of total billed charges,2.37,100,,,fee schedule,Pays 100% Medicare OPPS,2.13,279,
METHANOL BLOOD LEVEL,3084600,CDM,301,RC,80320,HCPCS,Outpatient,,,310,248,,263.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,16.36,120.37,,,fee schedule,120.37% of custom fee schedule,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,279,90,,,percent of total billed charges,90% of total billed charges,17.01,125.18,,,fee schedule,125.18% of custom fee schedule,212.97,68.7,,,percent of total billed charges,68.7% of total billed charges,248,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,179.8,58,,,percent of total billed charges,58% of total billed charges,16.36,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,263.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,16.36,279,
..STOOL CULTURE PANEL,3087045,CDM,306,RC,,,Outpatient,,,310,248,,263.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,279,90,,,percent of total billed charges,90% of total billed charges,108.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,212.97,68.7,,,percent of total billed charges,68.7% of total billed charges,248,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,179.8,58,,,percent of total billed charges,58% of total billed charges,63.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,263.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,63.15,279,
Test of body fluid other than blood to assess for bacteria,3087070,CDM,300,RC,87070,HCPCS,Outpatient,,,310,248,,263.5,85,,,percent of total billed charges,85% of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.2,130,,,fee schedule,Pays 130% Medicare OPPS,13.04,120.37,,,fee schedule,120.37% of custom fee schedule,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.79,102,,,fee schedule,Pays 102% Medicare OPPS,279,90,,,percent of total billed charges,90% of total billed charges,13.56,125.18,,,fee schedule,125.18% of custom fee schedule,212.97,68.7,,,percent of total billed charges,68.7% of total billed charges,248,80,,,percent of total billed charges,80 percent of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,7.75,90,,,fee schedule,Pays 90% Medicare OPPS,179.8,58,,,percent of total billed charges,58% of total billed charges,13.04,120.37,,,fee schedule,120.37% of custom fee schedule,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.2,130,,,fee schedule,Pays 130% Medicare OPPS,263.5,85,,,percent of total billed charges,85% of total billed charges,8.61,100,,,fee schedule,Pays 100% Medicare OPPS,7.75,279,
CULTURE ANAEROBIC,3087075,CDM,306,RC,87075,HCPCS,Outpatient,,,310,248,,263.5,85,,,percent of total billed charges,85% of total billed charges,9.47,100,,,fee schedule,Pays 100% Medicare OPPS,9.47,100,,,fee schedule,Pays 100% Medicare OPPS,9.47,100,,,fee schedule,Pays 100% Medicare OPPS,12.31,130,,,fee schedule,Pays 130% Medicare OPPS,14.32,120.37,,,fee schedule,120.37% of custom fee schedule,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.65,102,,,fee schedule,Pays 102% Medicare OPPS,279,90,,,percent of total billed charges,90% of total billed charges,14.9,125.18,,,fee schedule,125.18% of custom fee schedule,212.97,68.7,,,percent of total billed charges,68.7% of total billed charges,248,80,,,percent of total billed charges,80 percent of total billed charges,9.47,100,,,fee schedule,Pays 100% Medicare OPPS,8.52,90,,,fee schedule,Pays 90% Medicare OPPS,179.8,58,,,percent of total billed charges,58% of total billed charges,14.32,120.37,,,fee schedule,120.37% of custom fee schedule,9.47,100,,,fee schedule,Pays 100% Medicare OPPS,12.31,130,,,fee schedule,Pays 130% Medicare OPPS,263.5,85,,,percent of total billed charges,85% of total billed charges,9.47,100,,,fee schedule,Pays 100% Medicare OPPS,8.52,279,
A procedure used to determine if fungi are present in an area of the body,3087101,CDM,306,RC,87101,HCPCS,Outpatient,,,310,248,,263.5,85,,,percent of total billed charges,85% of total billed charges,7.71,100,,,fee schedule,Pays 100% Medicare OPPS,7.71,100,,,fee schedule,Pays 100% Medicare OPPS,7.71,100,,,fee schedule,Pays 100% Medicare OPPS,10.02,130,,,fee schedule,Pays 130% Medicare OPPS,11.66,120.37,,,fee schedule,120.37% of custom fee schedule,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,7.86,102,,,fee schedule,Pays 102% Medicare OPPS,279,90,,,percent of total billed charges,90% of total billed charges,12.13,125.18,,,fee schedule,125.18% of custom fee schedule,212.97,68.7,,,percent of total billed charges,68.7% of total billed charges,248,80,,,percent of total billed charges,80 percent of total billed charges,7.71,100,,,fee schedule,Pays 100% Medicare OPPS,6.93,90,,,fee schedule,Pays 90% Medicare OPPS,179.8,58,,,percent of total billed charges,58% of total billed charges,11.66,120.37,,,fee schedule,120.37% of custom fee schedule,7.71,100,,,fee schedule,Pays 100% Medicare OPPS,10.02,130,,,fee schedule,Pays 130% Medicare OPPS,263.5,85,,,percent of total billed charges,85% of total billed charges,7.71,100,,,fee schedule,Pays 100% Medicare OPPS,6.93,279,
CULTURE FUNGUS/other,3087102,CDM,306,RC,87102,HCPCS,Outpatient,,,310,248,,263.5,85,,,percent of total billed charges,85% of total billed charges,8.41,100,,,fee schedule,Pays 100% Medicare OPPS,8.41,100,,,fee schedule,Pays 100% Medicare OPPS,8.41,100,,,fee schedule,Pays 100% Medicare OPPS,10.93,130,,,fee schedule,Pays 130% Medicare OPPS,12.72,120.37,,,fee schedule,120.37% of custom fee schedule,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.57,102,,,fee schedule,Pays 102% Medicare OPPS,279,90,,,percent of total billed charges,90% of total billed charges,13.23,125.18,,,fee schedule,125.18% of custom fee schedule,212.97,68.7,,,percent of total billed charges,68.7% of total billed charges,248,80,,,percent of total billed charges,80 percent of total billed charges,8.41,100,,,fee schedule,Pays 100% Medicare OPPS,7.56,90,,,fee schedule,Pays 90% Medicare OPPS,179.8,58,,,percent of total billed charges,58% of total billed charges,12.72,120.37,,,fee schedule,120.37% of custom fee schedule,8.41,100,,,fee schedule,Pays 100% Medicare OPPS,10.93,130,,,fee schedule,Pays 130% Medicare OPPS,263.5,85,,,percent of total billed charges,85% of total billed charges,8.41,100,,,fee schedule,Pays 100% Medicare OPPS,7.56,279,
.CULTURE FUNGUS/BLOOD,3087103,CDM,306,RC,87103,HCPCS,Outpatient,,,310,248,,263.5,85,,,percent of total billed charges,85% of total billed charges,20.46,100,,,fee schedule,Pays 100% Medicare OPPS,20.46,100,,,fee schedule,Pays 100% Medicare OPPS,20.46,100,,,fee schedule,Pays 100% Medicare OPPS,26.59,130,,,fee schedule,Pays 130% Medicare OPPS,13.65,120.37,,,fee schedule,120.37% of custom fee schedule,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,20.86,102,,,fee schedule,Pays 102% Medicare OPPS,279,90,,,percent of total billed charges,90% of total billed charges,14.2,125.18,,,fee schedule,125.18% of custom fee schedule,212.97,68.7,,,percent of total billed charges,68.7% of total billed charges,248,80,,,percent of total billed charges,80 percent of total billed charges,20.46,100,,,fee schedule,Pays 100% Medicare OPPS,18.41,90,,,fee schedule,Pays 90% Medicare OPPS,179.8,58,,,percent of total billed charges,58% of total billed charges,13.65,120.37,,,fee schedule,120.37% of custom fee schedule,20.46,100,,,fee schedule,Pays 100% Medicare OPPS,26.59,130,,,fee schedule,Pays 130% Medicare OPPS,263.5,85,,,percent of total billed charges,85% of total billed charges,20.46,100,,,fee schedule,Pays 100% Medicare OPPS,13.65,279,
Mammography of both breasts-2 or more views,4376092,CDM,403,RC,77067,HCPCS,Outpatient,,,310,248,,263.5,85,,,percent of total billed charges,85% of total billed charges,83.86,100,,,fee schedule,Pays 100% Medicare OPPS,83.86,100,,,fee schedule,Pays 100% Medicare OPPS,83.86,100,,,fee schedule,Pays 100% Medicare OPPS,107.56,130,,,fee schedule,Pays 130% Medicare OPPS,63.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,174.22,56.5,,,percent of total billed charges,56.5 percent of total billed charges,85.54,102,,,fee schedule,Pays 102% Medicare OPPS,279,90,,,percent of total billed charges,90% of total billed charges,108.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,212.97,68.7,,,percent of total billed charges,68.7% of total billed charges,248,80,,,percent of total billed charges,80 percent of total billed charges,83.86,100,,,fee schedule,Pays 100% Medicare OPPS,75.47,90,,,fee schedule,Pays 90% Medicare OPPS,179.8,58,,,percent of total billed charges,58% of total billed charges,63.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,82.74,100,,,fee schedule,Pays 100% Medicare OPPS,107.56,130,,,fee schedule,Pays 130% Medicare OPPS,263.5,85,,,percent of total billed charges,85% of total billed charges,83.86,100,,,fee schedule,Pays 100% Medicare OPPS,63.15,279,
NM TC99M CHOLETEC (MEBROFENIN),4500011,CDM,343,RC,A9537,HCPCS,Outpatient,,,310,248,,263.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,279,90,,,percent of total billed charges,90% of total billed charges,108.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,212.97,68.7,,,percent of total billed charges,68.7% of total billed charges,248,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,179.8,58,,,percent of total billed charges,58% of total billed charges,63.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,263.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,63.15,279,
VACUUM CUP 004CB,7905096,CDM,270,RC,,,Outpatient,,,310,248,,263.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,279,90,,,percent of total billed charges,90% of total billed charges,108.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,212.97,68.7,,,percent of total billed charges,68.7% of total billed charges,248,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,179.8,58,,,percent of total billed charges,58% of total billed charges,63.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,263.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,63.15,279,
VENT BREATHING CIRCUIT SET 260167,7919116,CDM,272,RC,,,Outpatient,,,310,248,,263.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,279,90,,,percent of total billed charges,90% of total billed charges,108.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,212.97,68.7,,,percent of total billed charges,68.7% of total billed charges,248,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,179.8,58,,,percent of total billed charges,58% of total billed charges,63.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,263.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,63.15,279,
SURGIPRO MESH 1 X 4,7950215,CDM,278,RC,,,Both,,,310,248,,263.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,279,90,,,percent of total billed charges,90% of total billed charges,108.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,212.97,68.7,,,percent of total billed charges,68.7% of total billed charges,248,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,179.8,58,,,percent of total billed charges,58% of total billed charges,63.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,263.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,63.15,279,
TLS DRAIN,7950222,CDM,270,RC,,,Outpatient,,,310,248,,263.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,63.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,175.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,279,90,,,percent of total billed charges,90% of total billed charges,108.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,212.97,68.7,,,percent of total billed charges,68.7% of total billed charges,248,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,179.8,58,,,percent of total billed charges,58% of total billed charges,63.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,263.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,63.15,279,
DEBRIDEMENT MUSCLE EA ADDL 20 SQ CM,1511046,CDM,360,RC,11046,HCPCS,Outpatient,,,315,252,,267.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,64.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,,,,,other,Not reimbursable per contract,283.5,90,,,percent of total billed charges,90% of total billed charges,110.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,216.41,68.7,,,percent of total billed charges,68.7% of total billed charges,252,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,182.7,58,,,percent of total billed charges,58% of total billed charges,64.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,267.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,64.17,986.63,
BONE CUTTER ARTHROSCOPY 4.0MM X 13CM,1570818,CDM,272,RC,,,Outpatient,,,315,252,,267.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,64.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,283.5,90,,,percent of total billed charges,90% of total billed charges,110.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,216.41,68.7,,,percent of total billed charges,68.7% of total billed charges,252,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,182.7,58,,,percent of total billed charges,58% of total billed charges,64.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,267.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,64.17,283.5,
DISSECTOR CURVED 4.0MM X 13CM,1570819,CDM,272,RC,,,Outpatient,,,315,252,,267.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,64.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,283.5,90,,,percent of total billed charges,90% of total billed charges,110.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,216.41,68.7,,,percent of total billed charges,68.7% of total billed charges,252,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,182.7,58,,,percent of total billed charges,58% of total billed charges,64.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,267.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,64.17,283.5,
BURR OVAL FLUSHCUT 8 FLUTE 5.5MM X 13CM,1570823,CDM,272,RC,,,Outpatient,,,315,252,,267.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,64.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,283.5,90,,,percent of total billed charges,90% of total billed charges,110.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,216.41,68.7,,,percent of total billed charges,68.7% of total billed charges,252,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,182.7,58,,,percent of total billed charges,58% of total billed charges,64.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,267.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,64.17,283.5,
BONE CUTTER ARTHROSCOPY 5.5MM X 13CM,1570828,CDM,272,RC,,,Outpatient,,,315,252,,267.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,64.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,283.5,90,,,percent of total billed charges,90% of total billed charges,110.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,216.41,68.7,,,percent of total billed charges,68.7% of total billed charges,252,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,182.7,58,,,percent of total billed charges,58% of total billed charges,64.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,267.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,64.17,283.5,
CANNULA ERCP RX,1750028,CDM,272,RC,,,Outpatient,,,315,252,,267.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,64.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,283.5,90,,,percent of total billed charges,90% of total billed charges,110.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,216.41,68.7,,,percent of total billed charges,68.7% of total billed charges,252,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,182.7,58,,,percent of total billed charges,58% of total billed charges,64.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,267.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,64.17,283.5,
REMOVE INPACTED EAR WAX UNI,2069209,CDM,450,RC,69209,HCPCS,Outpatient,,,315,252,,267.75,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,65.72,130,,,fee schedule,Pays 130% Medicare OPPS,64.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,51,102,,,fee schedule,Pays 102% Medicare OPPS,283.5,90,,,percent of total billed charges,90% of total billed charges,110.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,216.41,68.7,,,percent of total billed charges,68.7% of total billed charges,252,80,,,percent of total billed charges,80 percent of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,45,90,,,fee schedule,Pays 90% Medicare OPPS,182.7,58,,,percent of total billed charges,58% of total billed charges,64.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,50.55,100,,,fee schedule,Pays 100% Medicare OPPS,65.72,130,,,fee schedule,Pays 130% Medicare OPPS,267.75,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,45,283.5,
PROSTIGMINE (NEOSTIGMINE) INJ 10MG/10ML,2601380,CDM,636,RC,J2710,HCPCS,Both,,,315,252,,267.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,0.96,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,283.5,90,,,percent of total billed charges,90% of total billed charges,1,125.18,,,fee schedule,125.18% of custom fee schedule,216.41,68.7,,,percent of total billed charges,68.7% of total billed charges,252,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,182.7,58,,,percent of total billed charges,58% of total billed charges,0.96,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,267.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.96,283.5,
TOBREX (TOBRAMYCIN) OPHT OINT,2603090,CDM,637,RC,,,Outpatient,,,315,252,,267.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,64.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,283.5,90,,,percent of total billed charges,90% of total billed charges,110.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,216.41,68.7,,,percent of total billed charges,68.7% of total billed charges,252,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,182.7,58,,,percent of total billed charges,58% of total billed charges,64.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,267.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,64.17,283.5,
FORCEP GRASPING POLYGRAB,7905044,CDM,272,RC,,,Outpatient,,,315,252,,267.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,64.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,177.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,283.5,90,,,percent of total billed charges,90% of total billed charges,110.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,216.41,68.7,,,percent of total billed charges,68.7% of total billed charges,252,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,182.7,58,,,percent of total billed charges,58% of total billed charges,64.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,267.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,64.17,283.5,
OR ACUITY LEVEL 1-B X 15 MIN,1501150,CDM,360,RC,,,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,65.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,288,90,,,percent of total billed charges,90% of total billed charges,112,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,185.6,58,,,percent of total billed charges,58% of total billed charges,65.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,272,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,65.18,288,
CEFTIN (CEFUROXIME 50ML) SUSP 250MG/5ML,2602337,CDM,637,RC,,,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,65.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,288,90,,,percent of total billed charges,90% of total billed charges,112,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,185.6,58,,,percent of total billed charges,58% of total billed charges,65.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,272,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,65.18,288,
pneumococcal Pneumococcal vaccine,2605096,CDM,636,RC,90732,HCPCS,Both,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,160.66,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,288,90,,,percent of total billed charges,90% of total billed charges,167.08,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,185.6,58,,,percent of total billed charges,58% of total billed charges,160.66,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,272,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,160.66,288,
ALPHA FETOPROTEIN TUMOR M,3000003,CDM,301,RC,82105,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,16.77,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,100,,,fee schedule,Pays 100% Medicare OPPS,21.8,130,,,fee schedule,Pays 130% Medicare OPPS,25.4,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.1,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,26.41,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,16.77,100,,,fee schedule,Pays 100% Medicare OPPS,15.09,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,25.4,120.37,,,fee schedule,120.37% of custom fee schedule,16.77,100,,,fee schedule,Pays 100% Medicare OPPS,21.8,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,16.77,100,,,fee schedule,Pays 100% Medicare OPPS,15.09,288,
"ALPHA FETOPROTEIN, MATERN",3000004,CDM,301,RC,82105,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,16.77,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,100,,,fee schedule,Pays 100% Medicare OPPS,21.8,130,,,fee schedule,Pays 130% Medicare OPPS,25.4,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.1,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,26.41,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,16.77,100,,,fee schedule,Pays 100% Medicare OPPS,15.09,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,25.4,120.37,,,fee schedule,120.37% of custom fee schedule,16.77,100,,,fee schedule,Pays 100% Medicare OPPS,21.8,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,16.77,100,,,fee schedule,Pays 100% Medicare OPPS,15.09,288,
Chemical test of the blood to measure presence or concentration of a substance in the blood,3000012,CDM,302,RC,83516,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.76,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,16.84,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,288,
C4 COMPLEMENT,3000035,CDM,302,RC,86160,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,12,100,,,fee schedule,Pays 100% Medicare OPPS,12,100,,,fee schedule,Pays 100% Medicare OPPS,12,100,,,fee schedule,Pays 100% Medicare OPPS,15.6,130,,,fee schedule,Pays 130% Medicare OPPS,18.18,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.24,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,18.9,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,12,100,,,fee schedule,Pays 100% Medicare OPPS,10.8,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,18.18,120.37,,,fee schedule,120.37% of custom fee schedule,12,100,,,fee schedule,Pays 100% Medicare OPPS,15.6,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,12,100,,,fee schedule,Pays 100% Medicare OPPS,10.8,288,
CARBAMAZEPINE (TEGRETOL) LEVEL,3000038,CDM,301,RC,80156,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,14.57,100,,,fee schedule,Pays 100% Medicare OPPS,14.57,100,,,fee schedule,Pays 100% Medicare OPPS,14.57,100,,,fee schedule,Pays 100% Medicare OPPS,18.94,130,,,fee schedule,Pays 130% Medicare OPPS,22.04,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.86,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,22.92,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,14.57,100,,,fee schedule,Pays 100% Medicare OPPS,13.11,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,22.04,120.37,,,fee schedule,120.37% of custom fee schedule,14.57,100,,,fee schedule,Pays 100% Medicare OPPS,18.94,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,14.57,100,,,fee schedule,Pays 100% Medicare OPPS,13.11,288,
"CHOLINESTERASE, SERUM",3000048,CDM,301,RC,82480,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,7.87,100,,,fee schedule,Pays 100% Medicare OPPS,7.87,100,,,fee schedule,Pays 100% Medicare OPPS,7.87,100,,,fee schedule,Pays 100% Medicare OPPS,10.23,130,,,fee schedule,Pays 130% Medicare OPPS,11.93,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.02,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,12.41,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,7.87,100,,,fee schedule,Pays 100% Medicare OPPS,7.08,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,11.93,120.37,,,fee schedule,120.37% of custom fee schedule,7.87,100,,,fee schedule,Pays 100% Medicare OPPS,10.23,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,7.87,100,,,fee schedule,Pays 100% Medicare OPPS,7.08,288,
CLONAZEPAM LEVEL,3000054,CDM,301,RC,80367,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,65.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,288,90,,,percent of total billed charges,90% of total billed charges,112,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,185.6,58,,,percent of total billed charges,58% of total billed charges,65.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,272,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,65.18,288,
3RD CYTOMEGALOVIRUS IgM Ab,3000081,CDM,302,RC,86645,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,16.85,100,,,fee schedule,Pays 100% Medicare OPPS,16.85,100,,,fee schedule,Pays 100% Medicare OPPS,16.85,100,,,fee schedule,Pays 100% Medicare OPPS,21.9,130,,,fee schedule,Pays 130% Medicare OPPS,25.51,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.18,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,26.53,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,16.85,100,,,fee schedule,Pays 100% Medicare OPPS,15.16,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,25.51,120.37,,,fee schedule,120.37% of custom fee schedule,16.85,100,,,fee schedule,Pays 100% Medicare OPPS,21.9,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,16.85,100,,,fee schedule,Pays 100% Medicare OPPS,15.16,288,
HTLV I/II,3000155,CDM,300,RC,86790,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.13,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,20.28,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,288,
Test to determine levels of immunoglobulins in the blood,3000162,CDM,301,RC,82784,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,12.09,130,,,fee schedule,Pays 130% Medicare OPPS,14.07,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.48,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,14.63,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,8.37,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,14.07,120.37,,,fee schedule,120.37% of custom fee schedule,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,12.09,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,9.3,100,,,fee schedule,Pays 100% Medicare OPPS,8.37,288,
Blood test to determine existence of certain bacterium that causes syphilis,3000200,CDM,302,RC,86780,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,13.24,100,,,fee schedule,Pays 100% Medicare OPPS,13.24,100,,,fee schedule,Pays 100% Medicare OPPS,13.24,100,,,fee schedule,Pays 100% Medicare OPPS,17.21,130,,,fee schedule,Pays 130% Medicare OPPS,65.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.5,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,112,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,13.24,100,,,fee schedule,Pays 100% Medicare OPPS,11.91,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,65.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,13.24,100,,,fee schedule,Pays 100% Medicare OPPS,17.21,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,13.24,100,,,fee schedule,Pays 100% Medicare OPPS,11.91,288,
MYOGLOBIN URINE,3000220,CDM,301,RC,83874,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,12.92,100,,,fee schedule,Pays 100% Medicare OPPS,12.92,100,,,fee schedule,Pays 100% Medicare OPPS,12.92,100,,,fee schedule,Pays 100% Medicare OPPS,16.79,130,,,fee schedule,Pays 130% Medicare OPPS,19.55,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.17,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,20.33,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,12.92,100,,,fee schedule,Pays 100% Medicare OPPS,11.62,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,19.55,120.37,,,fee schedule,120.37% of custom fee schedule,12.92,100,,,fee schedule,Pays 100% Medicare OPPS,16.79,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,12.92,100,,,fee schedule,Pays 100% Medicare OPPS,11.62,288,
RABIES ANTIBODY,3000249,CDM,302,RC,86790,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.13,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,20.28,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,288,
...ZRETICULIN,3000255,CDM,300,RC,86256,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,,,fee schedule,Pays 130% Medicare OPPS,18.25,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.29,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,18.98,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,10.84,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,18.25,120.37,,,fee schedule,120.37% of custom fee schedule,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,10.84,288,
T CELLS COUNT,3000294,CDM,302,RC,86359,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,37.72,100,,,fee schedule,Pays 100% Medicare OPPS,37.72,100,,,fee schedule,Pays 100% Medicare OPPS,37.72,100,,,fee schedule,Pays 100% Medicare OPPS,49.04,130,,,fee schedule,Pays 130% Medicare OPPS,35.65,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,38.48,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,37.08,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,37.72,100,,,fee schedule,Pays 100% Medicare OPPS,33.95,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,35.65,120.37,,,fee schedule,120.37% of custom fee schedule,37.72,100,,,fee schedule,Pays 100% Medicare OPPS,49.04,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,37.72,100,,,fee schedule,Pays 100% Medicare OPPS,33.95,288,
CORTISOL MORNING,3000387,CDM,301,RC,82533,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,16.3,100,,,fee schedule,Pays 100% Medicare OPPS,16.3,100,,,fee schedule,Pays 100% Medicare OPPS,16.3,100,,,fee schedule,Pays 100% Medicare OPPS,21.19,130,,,fee schedule,Pays 130% Medicare OPPS,24.68,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.62,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,25.66,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,16.3,100,,,fee schedule,Pays 100% Medicare OPPS,14.67,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,24.68,120.37,,,fee schedule,120.37% of custom fee schedule,16.3,100,,,fee schedule,Pays 100% Medicare OPPS,21.19,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,16.3,100,,,fee schedule,Pays 100% Medicare OPPS,14.67,288,
CORTISOL EVENING,3000388,CDM,301,RC,82533,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,16.3,100,,,fee schedule,Pays 100% Medicare OPPS,16.3,100,,,fee schedule,Pays 100% Medicare OPPS,16.3,100,,,fee schedule,Pays 100% Medicare OPPS,21.19,130,,,fee schedule,Pays 130% Medicare OPPS,24.68,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.62,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,25.66,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,16.3,100,,,fee schedule,Pays 100% Medicare OPPS,14.67,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,24.68,120.37,,,fee schedule,120.37% of custom fee schedule,16.3,100,,,fee schedule,Pays 100% Medicare OPPS,21.19,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,16.3,100,,,fee schedule,Pays 100% Medicare OPPS,14.67,288,
CLONAZEPAM LEVEL,3000709,CDM,301,RC,80346,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,28,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,288,90,,,percent of total billed charges,90% of total billed charges,29.12,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,185.6,58,,,percent of total billed charges,58% of total billed charges,28,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,272,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,28,288,
.BACTERIUM ANTIBODIES NES,3006609,CDM,300,RC,86609,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.13,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,20.28,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,288,
VALPROIC ACID LEVEL,3080164,CDM,301,RC,80164,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,13.54,100,,,fee schedule,Pays 100% Medicare OPPS,13.54,100,,,fee schedule,Pays 100% Medicare OPPS,13.54,100,,,fee schedule,Pays 100% Medicare OPPS,17.6,130,,,fee schedule,Pays 130% Medicare OPPS,17.18,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.81,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,17.86,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,13.54,100,,,fee schedule,Pays 100% Medicare OPPS,12.18,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,17.18,120.37,,,fee schedule,120.37% of custom fee schedule,13.54,100,,,fee schedule,Pays 100% Medicare OPPS,17.6,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,13.54,100,,,fee schedule,Pays 100% Medicare OPPS,12.18,288,
GENTAMICIN RANDOM,3080170,CDM,301,RC,80170,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,16.38,100,,,fee schedule,Pays 100% Medicare OPPS,16.38,100,,,fee schedule,Pays 100% Medicare OPPS,16.38,100,,,fee schedule,Pays 100% Medicare OPPS,21.29,130,,,fee schedule,Pays 130% Medicare OPPS,24.81,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.7,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,25.8,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,16.38,100,,,fee schedule,Pays 100% Medicare OPPS,14.74,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,24.81,120.37,,,fee schedule,120.37% of custom fee schedule,16.38,100,,,fee schedule,Pays 100% Medicare OPPS,21.29,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,16.38,100,,,fee schedule,Pays 100% Medicare OPPS,14.74,288,
GENTAMICIN PEAK,3080172,CDM,301,RC,80170,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,16.38,100,,,fee schedule,Pays 100% Medicare OPPS,16.38,100,,,fee schedule,Pays 100% Medicare OPPS,16.38,100,,,fee schedule,Pays 100% Medicare OPPS,21.29,130,,,fee schedule,Pays 130% Medicare OPPS,24.81,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.7,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,25.8,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,16.38,100,,,fee schedule,Pays 100% Medicare OPPS,14.74,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,24.81,120.37,,,fee schedule,120.37% of custom fee schedule,16.38,100,,,fee schedule,Pays 100% Medicare OPPS,21.29,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,16.38,100,,,fee schedule,Pays 100% Medicare OPPS,14.74,288,
GENTAMICIN TROUGH,3080175,CDM,301,RC,80170,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,16.38,100,,,fee schedule,Pays 100% Medicare OPPS,16.38,100,,,fee schedule,Pays 100% Medicare OPPS,16.38,100,,,fee schedule,Pays 100% Medicare OPPS,21.29,130,,,fee schedule,Pays 130% Medicare OPPS,24.81,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.7,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,25.8,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,16.38,100,,,fee schedule,Pays 100% Medicare OPPS,14.74,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,24.81,120.37,,,fee schedule,120.37% of custom fee schedule,16.38,100,,,fee schedule,Pays 100% Medicare OPPS,21.29,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,16.38,100,,,fee schedule,Pays 100% Medicare OPPS,14.74,288,
PHENOBARBITAL LEVEL,3080184,CDM,301,RC,80184,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,15.3,100,,,fee schedule,Pays 100% Medicare OPPS,15.3,100,,,fee schedule,Pays 100% Medicare OPPS,15.3,100,,,fee schedule,Pays 100% Medicare OPPS,19.89,130,,,fee schedule,Pays 130% Medicare OPPS,17.35,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.6,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,18.04,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,15.3,100,,,fee schedule,Pays 100% Medicare OPPS,13.77,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,17.35,120.37,,,fee schedule,120.37% of custom fee schedule,15.3,100,,,fee schedule,Pays 100% Medicare OPPS,19.89,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,15.3,100,,,fee schedule,Pays 100% Medicare OPPS,13.77,288,
DILANTIN LEVEL,3080185,CDM,301,RC,80185,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,13.25,100,,,fee schedule,Pays 100% Medicare OPPS,13.25,100,,,fee schedule,Pays 100% Medicare OPPS,13.25,100,,,fee schedule,Pays 100% Medicare OPPS,17.22,130,,,fee schedule,Pays 130% Medicare OPPS,20.07,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.51,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,20.87,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,13.25,100,,,fee schedule,Pays 100% Medicare OPPS,11.92,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,20.07,120.37,,,fee schedule,120.37% of custom fee schedule,13.25,100,,,fee schedule,Pays 100% Medicare OPPS,17.22,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,13.25,100,,,fee schedule,Pays 100% Medicare OPPS,11.92,288,
TOBRAMYCIN LEVEL,3080200,CDM,301,RC,80200,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,16.13,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,100,,,fee schedule,Pays 100% Medicare OPPS,20.96,130,,,fee schedule,Pays 130% Medicare OPPS,22.68,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.45,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,23.58,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,16.13,100,,,fee schedule,Pays 100% Medicare OPPS,14.51,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,22.68,120.37,,,fee schedule,120.37% of custom fee schedule,16.13,100,,,fee schedule,Pays 100% Medicare OPPS,20.96,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,16.13,100,,,fee schedule,Pays 100% Medicare OPPS,14.51,288,
"CHOLINESTERASE, PLASMA",3082480,CDM,301,RC,82480,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,7.87,100,,,fee schedule,Pays 100% Medicare OPPS,7.87,100,,,fee schedule,Pays 100% Medicare OPPS,7.87,100,,,fee schedule,Pays 100% Medicare OPPS,10.23,130,,,fee schedule,Pays 130% Medicare OPPS,11.93,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.02,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,12.41,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,7.87,100,,,fee schedule,Pays 100% Medicare OPPS,7.08,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,11.93,120.37,,,fee schedule,120.37% of custom fee schedule,7.87,100,,,fee schedule,Pays 100% Medicare OPPS,10.23,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,7.87,100,,,fee schedule,Pays 100% Medicare OPPS,7.08,288,
"CHOLINESTERASE, RBC",3082482,CDM,301,RC,82482,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,9.81,100,,,fee schedule,Pays 100% Medicare OPPS,9.81,100,,,fee schedule,Pays 100% Medicare OPPS,9.81,100,,,fee schedule,Pays 100% Medicare OPPS,12.75,130,,,fee schedule,Pays 130% Medicare OPPS,11.64,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,10,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,12.1,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,9.81,100,,,fee schedule,Pays 100% Medicare OPPS,8.82,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,11.64,120.37,,,fee schedule,120.37% of custom fee schedule,9.81,100,,,fee schedule,Pays 100% Medicare OPPS,12.75,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,9.81,100,,,fee schedule,Pays 100% Medicare OPPS,8.82,288,
CORTISOL RANDOM,3082533,CDM,301,RC,82533,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,16.3,100,,,fee schedule,Pays 100% Medicare OPPS,16.3,100,,,fee schedule,Pays 100% Medicare OPPS,16.3,100,,,fee schedule,Pays 100% Medicare OPPS,21.19,130,,,fee schedule,Pays 130% Medicare OPPS,24.68,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.62,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,25.66,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,16.3,100,,,fee schedule,Pays 100% Medicare OPPS,14.67,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,24.68,120.37,,,fee schedule,120.37% of custom fee schedule,16.3,100,,,fee schedule,Pays 100% Medicare OPPS,21.19,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,16.3,100,,,fee schedule,Pays 100% Medicare OPPS,14.67,288,
3RD CREATINE 24 HR URINE,3082540,CDM,301,RC,82540,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,4.63,100,,,fee schedule,Pays 100% Medicare OPPS,4.63,100,,,fee schedule,Pays 100% Medicare OPPS,4.63,100,,,fee schedule,Pays 100% Medicare OPPS,6.03,130,,,fee schedule,Pays 130% Medicare OPPS,7.02,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.73,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,7.3,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,4.63,100,,,fee schedule,Pays 100% Medicare OPPS,4.17,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,7.02,120.37,,,fee schedule,120.37% of custom fee schedule,4.63,100,,,fee schedule,Pays 100% Medicare OPPS,6.03,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,4.63,100,,,fee schedule,Pays 100% Medicare OPPS,4.17,288,
CPK ISOENZYMES,3082552,CDM,301,RC,82552,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,13.39,100,,,fee schedule,Pays 100% Medicare OPPS,13.39,100,,,fee schedule,Pays 100% Medicare OPPS,13.39,100,,,fee schedule,Pays 100% Medicare OPPS,17.4,130,,,fee schedule,Pays 130% Medicare OPPS,20.27,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.65,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,21.08,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,13.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,20.27,120.37,,,fee schedule,120.37% of custom fee schedule,13.39,100,,,fee schedule,Pays 100% Medicare OPPS,17.4,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,13.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,288,
GROWTH HORMONE LEVEL,3083003,CDM,301,RC,83003,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,16.67,100,,,fee schedule,Pays 100% Medicare OPPS,16.67,100,,,fee schedule,Pays 100% Medicare OPPS,16.67,100,,,fee schedule,Pays 100% Medicare OPPS,21.67,130,,,fee schedule,Pays 130% Medicare OPPS,21.55,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,22.41,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,16.67,100,,,fee schedule,Pays 100% Medicare OPPS,15,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,21.55,120.37,,,fee schedule,120.37% of custom fee schedule,16.67,100,,,fee schedule,Pays 100% Medicare OPPS,21.67,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,16.67,100,,,fee schedule,Pays 100% Medicare OPPS,15,288,
HEMOGLOBIN ELECTROPHORESIS,3083020,CDM,301,RC,83021,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,18.05,100,,,fee schedule,Pays 100% Medicare OPPS,18.05,100,,,fee schedule,Pays 100% Medicare OPPS,18.05,100,,,fee schedule,Pays 100% Medicare OPPS,23.47,130,,,fee schedule,Pays 130% Medicare OPPS,9.09,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.42,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,9.45,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,18.05,100,,,fee schedule,Pays 100% Medicare OPPS,16.25,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,9.09,120.37,,,fee schedule,120.37% of custom fee schedule,18.05,100,,,fee schedule,Pays 100% Medicare OPPS,23.47,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,18.05,100,,,fee schedule,Pays 100% Medicare OPPS,9.09,288,
17 HYDROXYCORTICOSTEROIDS,3083491,CDM,301,RC,83586,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,12.8,100,,,fee schedule,Pays 100% Medicare OPPS,12.8,100,,,fee schedule,Pays 100% Medicare OPPS,12.8,100,,,fee schedule,Pays 100% Medicare OPPS,16.64,130,,,fee schedule,Pays 130% Medicare OPPS,19.02,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.05,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,19.78,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,12.8,100,,,fee schedule,Pays 100% Medicare OPPS,11.52,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,19.02,120.37,,,fee schedule,120.37% of custom fee schedule,12.8,100,,,fee schedule,Pays 100% Medicare OPPS,16.64,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,12.8,100,,,fee schedule,Pays 100% Medicare OPPS,11.52,288,
"17 KETOGENIC STEROID, UA",3083582,CDM,301,RC,83586,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,12.8,100,,,fee schedule,Pays 100% Medicare OPPS,12.8,100,,,fee schedule,Pays 100% Medicare OPPS,12.8,100,,,fee schedule,Pays 100% Medicare OPPS,16.64,130,,,fee schedule,Pays 130% Medicare OPPS,19.02,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.05,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,19.78,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,12.8,100,,,fee schedule,Pays 100% Medicare OPPS,11.52,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,19.02,120.37,,,fee schedule,120.37% of custom fee schedule,12.8,100,,,fee schedule,Pays 100% Medicare OPPS,16.64,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,12.8,100,,,fee schedule,Pays 100% Medicare OPPS,11.52,288,
LDH ISOENZYMES,3083625,CDM,301,RC,83625,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,12.79,100,,,fee schedule,Pays 100% Medicare OPPS,12.79,100,,,fee schedule,Pays 100% Medicare OPPS,12.79,100,,,fee schedule,Pays 100% Medicare OPPS,16.62,130,,,fee schedule,Pays 130% Medicare OPPS,17.51,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.04,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,18.21,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,12.79,100,,,fee schedule,Pays 100% Medicare OPPS,11.51,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,17.51,120.37,,,fee schedule,120.37% of custom fee schedule,12.79,100,,,fee schedule,Pays 100% Medicare OPPS,16.62,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,12.79,100,,,fee schedule,Pays 100% Medicare OPPS,11.51,288,
MANGANESE SERUM LEVEL,3083785,CDM,300,RC,83785,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,26.65,100,,,fee schedule,Pays 100% Medicare OPPS,26.65,100,,,fee schedule,Pays 100% Medicare OPPS,26.65,100,,,fee schedule,Pays 100% Medicare OPPS,34.64,130,,,fee schedule,Pays 130% Medicare OPPS,37.22,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,27.18,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,38.71,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,26.65,100,,,fee schedule,Pays 100% Medicare OPPS,23.98,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,37.22,120.37,,,fee schedule,120.37% of custom fee schedule,26.65,100,,,fee schedule,Pays 100% Medicare OPPS,34.64,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,26.65,100,,,fee schedule,Pays 100% Medicare OPPS,23.98,288,
MERCURY 24 HOUR URINE,3083825,CDM,301,RC,83825,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,16.26,100,,,fee schedule,Pays 100% Medicare OPPS,16.26,100,,,fee schedule,Pays 100% Medicare OPPS,16.26,100,,,fee schedule,Pays 100% Medicare OPPS,21.13,130,,,fee schedule,Pays 130% Medicare OPPS,24.62,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.58,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,25.6,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,16.26,100,,,fee schedule,Pays 100% Medicare OPPS,14.63,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,24.62,120.37,,,fee schedule,120.37% of custom fee schedule,16.26,100,,,fee schedule,Pays 100% Medicare OPPS,21.13,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,16.26,100,,,fee schedule,Pays 100% Medicare OPPS,14.63,288,
MYOGLOBIN SERUM,3083874,CDM,301,RC,83874,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,12.92,100,,,fee schedule,Pays 100% Medicare OPPS,12.92,100,,,fee schedule,Pays 100% Medicare OPPS,12.92,100,,,fee schedule,Pays 100% Medicare OPPS,16.79,130,,,fee schedule,Pays 130% Medicare OPPS,19.55,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.17,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,20.33,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,12.92,100,,,fee schedule,Pays 100% Medicare OPPS,11.62,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,19.55,120.37,,,fee schedule,120.37% of custom fee schedule,12.92,100,,,fee schedule,Pays 100% Medicare OPPS,16.79,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,12.92,100,,,fee schedule,Pays 100% Medicare OPPS,11.62,288,
PH STOOL,3083986,CDM,301,RC,83986,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,3.58,100,,,fee schedule,Pays 100% Medicare OPPS,3.58,100,,,fee schedule,Pays 100% Medicare OPPS,3.58,100,,,fee schedule,Pays 100% Medicare OPPS,4.65,130,,,fee schedule,Pays 130% Medicare OPPS,5.42,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3.65,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,5.63,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,3.58,100,,,fee schedule,Pays 100% Medicare OPPS,3.22,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,5.42,120.37,,,fee schedule,120.37% of custom fee schedule,3.58,100,,,fee schedule,Pays 100% Medicare OPPS,4.65,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,3.58,100,,,fee schedule,Pays 100% Medicare OPPS,3.22,288,
TESTOSTERONE LEVEL,3084403,CDM,301,RC,84403,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,25.81,100,,,fee schedule,Pays 100% Medicare OPPS,25.81,100,,,fee schedule,Pays 100% Medicare OPPS,25.81,100,,,fee schedule,Pays 100% Medicare OPPS,33.55,130,,,fee schedule,Pays 130% Medicare OPPS,39.08,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,26.32,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,40.65,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,25.81,100,,,fee schedule,Pays 100% Medicare OPPS,23.22,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,39.08,120.37,,,fee schedule,120.37% of custom fee schedule,25.81,100,,,fee schedule,Pays 100% Medicare OPPS,33.55,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,25.81,100,,,fee schedule,Pays 100% Medicare OPPS,23.22,288,
THIAMINE LEVEL,3084425,CDM,301,RC,84425,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,21.23,100,,,fee schedule,Pays 100% Medicare OPPS,21.23,100,,,fee schedule,Pays 100% Medicare OPPS,21.23,100,,,fee schedule,Pays 100% Medicare OPPS,27.59,130,,,fee schedule,Pays 130% Medicare OPPS,32.14,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,21.65,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,33.42,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,21.23,100,,,fee schedule,Pays 100% Medicare OPPS,19.1,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,32.14,120.37,,,fee schedule,120.37% of custom fee schedule,21.23,100,,,fee schedule,Pays 100% Medicare OPPS,27.59,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,21.23,100,,,fee schedule,Pays 100% Medicare OPPS,19.1,288,
VMA RANDOM URINE,3084585,CDM,301,RC,84585,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,15.5,100,,,fee schedule,Pays 100% Medicare OPPS,15.5,100,,,fee schedule,Pays 100% Medicare OPPS,15.5,100,,,fee schedule,Pays 100% Medicare OPPS,20.15,130,,,fee schedule,Pays 130% Medicare OPPS,23.46,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.81,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,24.4,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,15.5,100,,,fee schedule,Pays 100% Medicare OPPS,13.95,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,23.46,120.37,,,fee schedule,120.37% of custom fee schedule,15.5,100,,,fee schedule,Pays 100% Medicare OPPS,20.15,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,15.5,100,,,fee schedule,Pays 100% Medicare OPPS,13.95,288,
3RD PREGNANCY BETA (QUANT),3084702,CDM,301,RC,84702,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,15.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.05,100,,,fee schedule,Pays 100% Medicare OPPS,19.56,130,,,fee schedule,Pays 130% Medicare OPPS,9.71,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.35,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,10.1,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,15.05,100,,,fee schedule,Pays 100% Medicare OPPS,13.54,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,9.71,120.37,,,fee schedule,120.37% of custom fee schedule,15.05,100,,,fee schedule,Pays 100% Medicare OPPS,19.56,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,15.05,100,,,fee schedule,Pays 100% Medicare OPPS,9.71,288,
3RD LUPUS TYPE ANTICOAG,3085400,CDM,305,RC,85400,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,7.71,100,,,fee schedule,Pays 100% Medicare OPPS,7.71,100,,,fee schedule,Pays 100% Medicare OPPS,7.71,100,,,fee schedule,Pays 100% Medicare OPPS,10.02,130,,,fee schedule,Pays 130% Medicare OPPS,13.39,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,7.86,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,13.92,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,7.71,100,,,fee schedule,Pays 100% Medicare OPPS,6.93,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,13.39,120.37,,,fee schedule,120.37% of custom fee schedule,7.71,100,,,fee schedule,Pays 100% Medicare OPPS,10.02,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,7.71,100,,,fee schedule,Pays 100% Medicare OPPS,6.93,288,
C3 COMPLEMENT,3086160,CDM,302,RC,86160,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,12,100,,,fee schedule,Pays 100% Medicare OPPS,12,100,,,fee schedule,Pays 100% Medicare OPPS,12,100,,,fee schedule,Pays 100% Medicare OPPS,15.6,130,,,fee schedule,Pays 130% Medicare OPPS,18.18,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.24,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,18.9,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,12,100,,,fee schedule,Pays 100% Medicare OPPS,10.8,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,18.18,120.37,,,fee schedule,120.37% of custom fee schedule,12,100,,,fee schedule,Pays 100% Medicare OPPS,15.6,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,12,100,,,fee schedule,Pays 100% Medicare OPPS,10.8,288,
3RD C1-ESTERASE INHIBITOR,3086161,CDM,302,RC,86161,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,12,100,,,fee schedule,Pays 100% Medicare OPPS,12,100,,,fee schedule,Pays 100% Medicare OPPS,12,100,,,fee schedule,Pays 100% Medicare OPPS,15.6,130,,,fee schedule,Pays 130% Medicare OPPS,18.18,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.24,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,18.9,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,12,100,,,fee schedule,Pays 100% Medicare OPPS,10.8,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,18.18,120.37,,,fee schedule,120.37% of custom fee schedule,12,100,,,fee schedule,Pays 100% Medicare OPPS,15.6,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,12,100,,,fee schedule,Pays 100% Medicare OPPS,10.8,288,
CH 50 COMPLEMENT,3086162,CDM,302,RC,86162,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,20.32,100,,,fee schedule,Pays 100% Medicare OPPS,20.32,100,,,fee schedule,Pays 100% Medicare OPPS,20.32,100,,,fee schedule,Pays 100% Medicare OPPS,26.41,130,,,fee schedule,Pays 130% Medicare OPPS,30.75,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,20.72,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,31.98,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,20.32,100,,,fee schedule,Pays 100% Medicare OPPS,18.28,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,30.75,120.37,,,fee schedule,120.37% of custom fee schedule,20.32,100,,,fee schedule,Pays 100% Medicare OPPS,26.41,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,20.32,100,,,fee schedule,Pays 100% Medicare OPPS,18.28,288,
3RD RETICULIN IgA AB,3086256,CDM,300,RC,86255,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,,,fee schedule,Pays 130% Medicare OPPS,18.25,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.29,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,18.98,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,10.84,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,18.25,120.37,,,fee schedule,120.37% of custom fee schedule,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,10.84,288,
CD3/C19,3086359,CDM,300,RC,86359,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,37.72,100,,,fee schedule,Pays 100% Medicare OPPS,37.72,100,,,fee schedule,Pays 100% Medicare OPPS,37.72,100,,,fee schedule,Pays 100% Medicare OPPS,49.04,130,,,fee schedule,Pays 130% Medicare OPPS,35.65,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,38.48,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,37.08,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,37.72,100,,,fee schedule,Pays 100% Medicare OPPS,33.95,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,35.65,120.37,,,fee schedule,120.37% of custom fee schedule,37.72,100,,,fee schedule,Pays 100% Medicare OPPS,49.04,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,37.72,100,,,fee schedule,Pays 100% Medicare OPPS,33.95,288,
3RD TETANUS ANTIBODIES,3086774,CDM,302,RC,86774,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,14.8,100,,,fee schedule,Pays 100% Medicare OPPS,14.8,100,,,fee schedule,Pays 100% Medicare OPPS,14.8,100,,,fee schedule,Pays 100% Medicare OPPS,19.24,130,,,fee schedule,Pays 130% Medicare OPPS,22.4,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.09,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,23.3,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,14.8,100,,,fee schedule,Pays 100% Medicare OPPS,13.32,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,22.4,120.37,,,fee schedule,120.37% of custom fee schedule,14.8,100,,,fee schedule,Pays 100% Medicare OPPS,19.24,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,14.8,100,,,fee schedule,Pays 100% Medicare OPPS,13.32,288,
.PRADER-WILLI BY FISH-B,3088365,CDM,312,RC,88365,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,179.8,130,,,fee schedule,Pays 130% Medicare OPPS,106.14,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,136.65,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,110.38,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,120.57,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,106.14,120.37,,,fee schedule,120.37% of custom fee schedule,138.31,100,,,fee schedule,Pays 100% Medicare OPPS,179.8,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,106.14,288,
GASTRIC ANALYSIS,3089130,CDM,309,RC,82930,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,6.71,100,,,fee schedule,Pays 100% Medicare OPPS,6.71,100,,,fee schedule,Pays 100% Medicare OPPS,6.71,100,,,fee schedule,Pays 100% Medicare OPPS,8.72,130,,,fee schedule,Pays 130% Medicare OPPS,26.78,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.84,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,27.85,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,6.71,100,,,fee schedule,Pays 100% Medicare OPPS,6.03,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,26.78,120.37,,,fee schedule,120.37% of custom fee schedule,6.71,100,,,fee schedule,Pays 100% Medicare OPPS,8.72,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,6.71,100,,,fee schedule,Pays 100% Medicare OPPS,6.03,288,
SPERM COUNT,3089320,CDM,309,RC,89320,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,12.31,100,,,fee schedule,Pays 100% Medicare OPPS,12.31,100,,,fee schedule,Pays 100% Medicare OPPS,12.31,100,,,fee schedule,Pays 100% Medicare OPPS,16,130,,,fee schedule,Pays 130% Medicare OPPS,8.73,120.37,,,fee schedule,120.37% of custom fee schedule,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.55,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,9.08,125.18,,,fee schedule,125.18% of custom fee schedule,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,12.31,100,,,fee schedule,Pays 100% Medicare OPPS,11.07,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,8.73,120.37,,,fee schedule,120.37% of custom fee schedule,12.31,100,,,fee schedule,Pays 100% Medicare OPPS,16,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,12.31,100,,,fee schedule,Pays 100% Medicare OPPS,8.73,288,
EKG,5693005,CDM,730,RC,93005,HCPCS,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,65.72,130,,,fee schedule,Pays 130% Medicare OPPS,65.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,51,102,,,fee schedule,Pays 102% Medicare OPPS,288,90,,,percent of total billed charges,90% of total billed charges,112,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,45,90,,,fee schedule,Pays 90% Medicare OPPS,185.6,58,,,percent of total billed charges,58% of total billed charges,65.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,50.55,100,,,fee schedule,Pays 100% Medicare OPPS,65.72,130,,,fee schedule,Pays 130% Medicare OPPS,272,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,45,288,
LUMBAR PUNCTURE TRAY SPINA,7905416,CDM,270,RC,,,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,65.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,288,90,,,percent of total billed charges,90% of total billed charges,112,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,185.6,58,,,percent of total billed charges,58% of total billed charges,65.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,272,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,65.18,288,
NEEDLE INTRAOSSEOUS COOK,7905937,CDM,272,RC,,,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,65.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,288,90,,,percent of total billed charges,90% of total billed charges,112,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,185.6,58,,,percent of total billed charges,58% of total billed charges,65.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,272,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,65.18,288,
ENDO CLIP APPLIER ER320,7950143,CDM,272,RC,,,Outpatient,,,320,256,,272,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,65.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,180.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,288,90,,,percent of total billed charges,90% of total billed charges,112,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,219.84,68.7,,,percent of total billed charges,68.7% of total billed charges,256,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,185.6,58,,,percent of total billed charges,58% of total billed charges,65.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,272,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,65.18,288,
.....MRI GADOLYNIUM PER 20 ML,440025,CDM,255,RC,A9576,HCPCS,Outpatient,,,325,260,,276.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,66.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,292.5,90,,,percent of total billed charges,90% of total billed charges,113.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,223.28,68.7,,,percent of total billed charges,68.7% of total billed charges,260,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,188.5,58,,,percent of total billed charges,58% of total billed charges,66.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,66.2,292.5,
INS TEMP BLADDER CATH,1551702,CDM,761,RC,51702,HCPCS,Outpatient,,,325,260,,276.25,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,66.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,292.5,90,,,percent of total billed charges,90% of total billed charges,113.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,223.28,68.7,,,percent of total billed charges,68.7% of total billed charges,260,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,188.5,58,,,percent of total billed charges,58% of total billed charges,66.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,276.25,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,66.2,292.5,
LEVAQUIN 500MG IV PREMIX,2605191,CDM,636,RC,J1956,HCPCS,Both,,,325,260,,276.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,66.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,292.5,90,,,percent of total billed charges,90% of total billed charges,113.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,223.28,68.7,,,percent of total billed charges,68.7% of total billed charges,260,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,188.5,58,,,percent of total billed charges,58% of total billed charges,66.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,276.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,66.2,292.5,
IBUPROFEN LEVEL,3000158,CDM,301,RC,80329,HCPCS,Outpatient,,,325,260,,276.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,30.63,120.37,,,fee schedule,120.37% of custom fee schedule,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,292.5,90,,,percent of total billed charges,90% of total billed charges,31.86,125.18,,,fee schedule,125.18% of custom fee schedule,223.28,68.7,,,percent of total billed charges,68.7% of total billed charges,260,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,188.5,58,,,percent of total billed charges,58% of total billed charges,30.63,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,276.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,30.63,292.5,
PM-SCL 100 AB,3000396,CDM,302,RC,86235,HCPCS,Outpatient,,,325,260,,276.25,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.28,102,,,fee schedule,Pays 102% Medicare OPPS,292.5,90,,,percent of total billed charges,90% of total billed charges,28.23,125.18,,,fee schedule,125.18% of custom fee schedule,223.28,68.7,,,percent of total billed charges,68.7% of total billed charges,260,80,,,percent of total billed charges,80 percent of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,90,,,fee schedule,Pays 90% Medicare OPPS,188.5,58,,,percent of total billed charges,58% of total billed charges,27.14,120.37,,,fee schedule,120.37% of custom fee schedule,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,23.3,130,,,fee schedule,Pays 130% Medicare OPPS,276.25,85,,,percent of total billed charges,85% of total billed charges,17.93,100,,,fee schedule,Pays 100% Medicare OPPS,16.13,292.5,
3RD ACETYLCHOLINE RECEPTOR MODULATING AB,3000560,CDM,301,RC,83519,HCPCS,Outpatient,,,325,260,,276.25,85,,,percent of total billed charges,85% of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,23.92,130,,,fee schedule,Pays 130% Medicare OPPS,20.45,120.37,,,fee schedule,120.37% of custom fee schedule,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.76,102,,,fee schedule,Pays 102% Medicare OPPS,292.5,90,,,percent of total billed charges,90% of total billed charges,21.27,125.18,,,fee schedule,125.18% of custom fee schedule,223.28,68.7,,,percent of total billed charges,68.7% of total billed charges,260,80,,,percent of total billed charges,80 percent of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.55,90,,,fee schedule,Pays 90% Medicare OPPS,188.5,58,,,percent of total billed charges,58% of total billed charges,20.45,120.37,,,fee schedule,120.37% of custom fee schedule,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,23.92,130,,,fee schedule,Pays 130% Medicare OPPS,276.25,85,,,percent of total billed charges,85% of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.55,292.5,
PROCAINAMIDE LEVEL,3080190,CDM,301,RC,80192,HCPCS,Outpatient,,,325,260,,276.25,85,,,percent of total billed charges,85% of total billed charges,16.75,100,,,fee schedule,Pays 100% Medicare OPPS,16.75,100,,,fee schedule,Pays 100% Medicare OPPS,16.75,100,,,fee schedule,Pays 100% Medicare OPPS,21.77,130,,,fee schedule,Pays 130% Medicare OPPS,25.36,120.37,,,fee schedule,120.37% of custom fee schedule,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.08,102,,,fee schedule,Pays 102% Medicare OPPS,292.5,90,,,percent of total billed charges,90% of total billed charges,26.38,125.18,,,fee schedule,125.18% of custom fee schedule,223.28,68.7,,,percent of total billed charges,68.7% of total billed charges,260,80,,,percent of total billed charges,80 percent of total billed charges,16.75,100,,,fee schedule,Pays 100% Medicare OPPS,15.07,90,,,fee schedule,Pays 90% Medicare OPPS,188.5,58,,,percent of total billed charges,58% of total billed charges,25.36,120.37,,,fee schedule,120.37% of custom fee schedule,16.75,100,,,fee schedule,Pays 100% Medicare OPPS,21.77,130,,,fee schedule,Pays 130% Medicare OPPS,276.25,85,,,percent of total billed charges,85% of total billed charges,16.75,100,,,fee schedule,Pays 100% Medicare OPPS,15.07,292.5,
AMYLASE ISOENYZMES,3082150,CDM,301,RC,82150,HCPCS,Outpatient,,,325,260,,276.25,85,,,percent of total billed charges,85% of total billed charges,6.48,100,,,fee schedule,Pays 100% Medicare OPPS,6.48,100,,,fee schedule,Pays 100% Medicare OPPS,6.48,100,,,fee schedule,Pays 100% Medicare OPPS,8.42,130,,,fee schedule,Pays 130% Medicare OPPS,9.81,120.37,,,fee schedule,120.37% of custom fee schedule,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.6,102,,,fee schedule,Pays 102% Medicare OPPS,292.5,90,,,percent of total billed charges,90% of total billed charges,10.2,125.18,,,fee schedule,125.18% of custom fee schedule,223.28,68.7,,,percent of total billed charges,68.7% of total billed charges,260,80,,,percent of total billed charges,80 percent of total billed charges,6.48,100,,,fee schedule,Pays 100% Medicare OPPS,5.83,90,,,fee schedule,Pays 90% Medicare OPPS,188.5,58,,,percent of total billed charges,58% of total billed charges,9.81,120.37,,,fee schedule,120.37% of custom fee schedule,6.48,100,,,fee schedule,Pays 100% Medicare OPPS,8.42,130,,,fee schedule,Pays 130% Medicare OPPS,276.25,85,,,percent of total billed charges,85% of total billed charges,6.48,100,,,fee schedule,Pays 100% Medicare OPPS,5.83,292.5,
RSV (SWAB),3087420,CDM,306,RC,87420,HCPCS,Outpatient,,,325,260,,276.25,85,,,percent of total billed charges,85% of total billed charges,13.91,100,,,fee schedule,Pays 100% Medicare OPPS,13.91,100,,,fee schedule,Pays 100% Medicare OPPS,13.91,100,,,fee schedule,Pays 100% Medicare OPPS,18.08,130,,,fee schedule,Pays 130% Medicare OPPS,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.18,102,,,fee schedule,Pays 102% Medicare OPPS,292.5,90,,,percent of total billed charges,90% of total billed charges,18.88,125.18,,,fee schedule,125.18% of custom fee schedule,223.28,68.7,,,percent of total billed charges,68.7% of total billed charges,260,80,,,percent of total billed charges,80 percent of total billed charges,13.91,100,,,fee schedule,Pays 100% Medicare OPPS,12.51,90,,,fee schedule,Pays 90% Medicare OPPS,188.5,58,,,percent of total billed charges,58% of total billed charges,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,13.91,100,,,fee schedule,Pays 100% Medicare OPPS,18.08,130,,,fee schedule,Pays 130% Medicare OPPS,276.25,85,,,percent of total billed charges,85% of total billed charges,13.91,100,,,fee schedule,Pays 100% Medicare OPPS,12.51,292.5,
FOLEY CATH INSERTION SIMP,4051702,CDM,450,RC,51702,HCPCS,Outpatient,,,325,260,,276.25,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,66.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,292.5,90,,,percent of total billed charges,90% of total billed charges,113.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,223.28,68.7,,,percent of total billed charges,68.7% of total billed charges,260,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,188.5,58,,,percent of total billed charges,58% of total billed charges,66.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,276.25,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,66.2,292.5,
XR NECK SOFT TISSUE,4070360,CDM,320,RC,70360,HCPCS,Outpatient,,,325,260,,276.25,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,66.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,183.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,182.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,292.5,90,,,percent of total billed charges,90% of total billed charges,113.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,223.28,68.7,,,percent of total billed charges,68.7% of total billed charges,260,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,188.5,58,,,percent of total billed charges,58% of total billed charges,66.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,276.25,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,292.5,
SURGIPRO MESH,7905207,CDM,278,RC,,,Both,,,325,260,,276.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,66.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,292.5,90,,,percent of total billed charges,90% of total billed charges,113.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,223.28,68.7,,,percent of total billed charges,68.7% of total billed charges,260,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,188.5,58,,,percent of total billed charges,58% of total billed charges,66.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,276.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,66.2,292.5,
HEMABATE (CARBOPROST) 250MCG/1ML AMP,2600083,CDM,636,RC,,,Both,,,330,264,,280.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,67.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,297,90,,,percent of total billed charges,90% of total billed charges,115.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,226.71,68.7,,,percent of total billed charges,68.7% of total billed charges,264,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,191.4,58,,,percent of total billed charges,58% of total billed charges,67.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,280.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,67.22,297,
DRILL BIT 2.5 MM QC GOLD 110 MM,1570025,CDM,278,RC,A4649,HCPCS,Both,,,335,268,,284.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,68.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,301.5,90,,,percent of total billed charges,90% of total billed charges,117.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,230.15,68.7,,,percent of total billed charges,68.7% of total billed charges,268,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,194.3,58,,,percent of total billed charges,58% of total billed charges,68.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,284.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,68.24,301.5,
DRILL BIT 2.5 MM QC 110 MM,1570026,CDM,278,RC,A4649,HCPCS,Both,,,335,268,,284.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,68.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,301.5,90,,,percent of total billed charges,90% of total billed charges,117.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,230.15,68.7,,,percent of total billed charges,68.7% of total billed charges,268,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,194.3,58,,,percent of total billed charges,58% of total billed charges,68.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,284.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,68.24,301.5,
FLUVIRIN INFLU VACCINE : ADULT (>4YRS),2600155,CDM,636,RC,Q2039,HCPCS,Both,,,335,268,,284.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,68.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,301.5,90,,,percent of total billed charges,90% of total billed charges,117.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,230.15,68.7,,,percent of total billed charges,68.7% of total billed charges,268,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,194.3,58,,,percent of total billed charges,58% of total billed charges,68.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,284.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,68.24,301.5,
Testing for presence of drug,3000089,CDM,301,RC,80307,HCPCS,Outpatient,,,335,268,,284.75,85,,,percent of total billed charges,85% of total billed charges,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,80.78,130,,,fee schedule,Pays 130% Medicare OPPS,73.62,120.37,,,fee schedule,120.37% of custom fee schedule,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,63.38,102,,,fee schedule,Pays 102% Medicare OPPS,301.5,90,,,percent of total billed charges,90% of total billed charges,76.56,125.18,,,fee schedule,125.18% of custom fee schedule,230.15,68.7,,,percent of total billed charges,68.7% of total billed charges,268,80,,,percent of total billed charges,80 percent of total billed charges,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,55.92,90,,,fee schedule,Pays 90% Medicare OPPS,194.3,58,,,percent of total billed charges,58% of total billed charges,73.62,120.37,,,fee schedule,120.37% of custom fee schedule,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,80.78,130,,,fee schedule,Pays 130% Medicare OPPS,284.75,85,,,percent of total billed charges,85% of total billed charges,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,55.92,301.5,
"DRUG SCREEN, NIDA",3000091,CDM,301,RC,80377,HCPCS,Outpatient,,,335,268,,284.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,68.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,301.5,90,,,percent of total billed charges,90% of total billed charges,117.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,230.15,68.7,,,percent of total billed charges,68.7% of total billed charges,268,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,194.3,58,,,percent of total billed charges,58% of total billed charges,68.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,284.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,68.24,301.5,
.6-METHYLMERCAPTOPURINE,3000641,CDM,301,RC,80299,HCPCS,Outpatient,,,335,268,,284.75,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.01,102,,,fee schedule,Pays 102% Medicare OPPS,301.5,90,,,percent of total billed charges,90% of total billed charges,18.95,125.18,,,fee schedule,125.18% of custom fee schedule,230.15,68.7,,,percent of total billed charges,68.7% of total billed charges,268,80,,,percent of total billed charges,80 percent of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,90,,,fee schedule,Pays 90% Medicare OPPS,194.3,58,,,percent of total billed charges,58% of total billed charges,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,284.75,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,301.5,
.6-THIOGUANINE,3000642,CDM,301,RC,80299,HCPCS,Outpatient,,,335,268,,284.75,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.01,102,,,fee schedule,Pays 102% Medicare OPPS,301.5,90,,,percent of total billed charges,90% of total billed charges,18.95,125.18,,,fee schedule,125.18% of custom fee schedule,230.15,68.7,,,percent of total billed charges,68.7% of total billed charges,268,80,,,percent of total billed charges,80 percent of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,90,,,fee schedule,Pays 90% Medicare OPPS,194.3,58,,,percent of total billed charges,58% of total billed charges,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,284.75,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,301.5,
.MOLECULAR CYTO DNA PROBE,3088271,CDM,311,RC,88271,HCPCS,Outpatient,,,335,268,,284.75,85,,,percent of total billed charges,85% of total billed charges,21.42,100,,,fee schedule,Pays 100% Medicare OPPS,21.42,100,,,fee schedule,Pays 100% Medicare OPPS,21.42,100,,,fee schedule,Pays 100% Medicare OPPS,27.84,130,,,fee schedule,Pays 130% Medicare OPPS,32.43,120.37,,,fee schedule,120.37% of custom fee schedule,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,21.84,102,,,fee schedule,Pays 102% Medicare OPPS,301.5,90,,,percent of total billed charges,90% of total billed charges,33.72,125.18,,,fee schedule,125.18% of custom fee schedule,230.15,68.7,,,percent of total billed charges,68.7% of total billed charges,268,80,,,percent of total billed charges,80 percent of total billed charges,21.42,100,,,fee schedule,Pays 100% Medicare OPPS,19.27,90,,,fee schedule,Pays 90% Medicare OPPS,194.3,58,,,percent of total billed charges,58% of total billed charges,32.43,120.37,,,fee schedule,120.37% of custom fee schedule,21.42,100,,,fee schedule,Pays 100% Medicare OPPS,27.84,130,,,fee schedule,Pays 130% Medicare OPPS,284.75,85,,,percent of total billed charges,85% of total billed charges,21.42,100,,,fee schedule,Pays 100% Medicare OPPS,19.27,301.5,
ARM SLEEVE,5007119,CDM,270,RC,,,Outpatient,,,335,268,,284.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,68.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,301.5,90,,,percent of total billed charges,90% of total billed charges,117.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,230.15,68.7,,,percent of total billed charges,68.7% of total billed charges,268,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,194.3,58,,,percent of total billed charges,58% of total billed charges,68.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,284.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,68.24,301.5,
Outpatient visit of established patient not requiring a physician,5099211,CDM,420,RC,99211,HCPCS,Outpatient,,,335,268,,284.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,68.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,301.5,90,,,percent of total billed charges,90% of total billed charges,117.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,230.15,68.7,,,percent of total billed charges,68.7% of total billed charges,268,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,194.3,58,,,percent of total billed charges,58% of total billed charges,68.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,284.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,68.24,301.5,
Outpatient visit of established patient not requiring a physician,5199211,CDM,430,RC,99211,HCPCS,Outpatient,,,335,268,,284.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,68.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,301.5,90,,,percent of total billed charges,90% of total billed charges,117.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,230.15,68.7,,,percent of total billed charges,68.7% of total billed charges,268,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,194.3,58,,,percent of total billed charges,58% of total billed charges,68.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,284.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,68.24,301.5,
BANDAGE PROFORE,7905425,CDM,270,RC,,,Outpatient,,,335,268,,284.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,68.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,301.5,90,,,percent of total billed charges,90% of total billed charges,117.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,230.15,68.7,,,percent of total billed charges,68.7% of total billed charges,268,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,194.3,58,,,percent of total billed charges,58% of total billed charges,68.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,284.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,68.24,301.5,
CWV DRAIN 7 MM,7905742,CDM,270,RC,,,Outpatient,,,335,268,,284.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,68.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,301.5,90,,,percent of total billed charges,90% of total billed charges,117.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,230.15,68.7,,,percent of total billed charges,68.7% of total billed charges,268,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,194.3,58,,,percent of total billed charges,58% of total billed charges,68.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,284.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,68.24,301.5,
Group psychotherapy,9090853,CDM,900,RC,90853,HCPCS,Outpatient,,,335,268,,284.75,85,,,percent of total billed charges,85% of total billed charges,67.2,100,,,fee schedule,Pays 100% Medicare OPPS,67.2,100,,,fee schedule,Pays 100% Medicare OPPS,67.2,100,,,fee schedule,Pays 100% Medicare OPPS,86.72,130,,,fee schedule,Pays 130% Medicare OPPS,68.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,189.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,68.55,102,,,fee schedule,Pays 102% Medicare OPPS,301.5,90,,,percent of total billed charges,90% of total billed charges,117.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,230.15,68.7,,,percent of total billed charges,68.7% of total billed charges,268,80,,,percent of total billed charges,80 percent of total billed charges,67.2,100,,,fee schedule,Pays 100% Medicare OPPS,60.48,90,,,fee schedule,Pays 90% Medicare OPPS,194.3,58,,,percent of total billed charges,58% of total billed charges,68.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,66.7,100,,,fee schedule,Pays 100% Medicare OPPS,86.72,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,67.2,100,,,fee schedule,Pays 100% Medicare OPPS,60.48,301.5,
MARKER BREAST BIOPSY HYDROMARK T4,7950300,CDM,272,RC,,,Outpatient,,,340,272,,289,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,69.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,192.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,192.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,192.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,192.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,306,90,,,percent of total billed charges,90% of total billed charges,119,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,233.58,68.7,,,percent of total billed charges,68.7% of total billed charges,272,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,197.2,58,,,percent of total billed charges,58% of total billed charges,69.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,289,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,69.26,306,
MARKER BREAST BIOPSY HYDROMARK T3,7950310,CDM,272,RC,,,Outpatient,,,340,272,,289,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,69.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,192.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,192.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,192.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,192.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,306,90,,,percent of total billed charges,90% of total billed charges,119,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,233.58,68.7,,,percent of total billed charges,68.7% of total billed charges,272,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,197.2,58,,,percent of total billed charges,58% of total billed charges,69.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,289,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,69.26,306,
OROGRASTRIC TUBE PLACEMEN,2043753,CDM,450,RC,43752,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,243.8,100,,,fee schedule,Pays 100% Medicare OPPS,243.8,100,,,fee schedule,Pays 100% Medicare OPPS,243.8,100,,,fee schedule,Pays 100% Medicare OPPS,431.73,130,,,fee schedule,Pays 130% Medicare OPPS,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,248.67,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,120.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,243.8,100,,,fee schedule,Pays 100% Medicare OPPS,219.42,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,332.1,100,,,fee schedule,Pays 100% Medicare OPPS,431.73,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,243.8,100,,,fee schedule,Pays 100% Medicare OPPS,70.28,431.73,
GASTRIC LAVAGE,2091105,CDM,450,RC,43753,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,320.23,130,,,fee schedule,Pays 130% Medicare OPPS,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,242.49,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,120.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,213.96,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,246.33,100,,,fee schedule,Pays 100% Medicare OPPS,320.23,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,70.28,320.23,
NON-FORMULARY OPHTH DROP,2600099,CDM,637,RC,,,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,310.5,90,,,percent of total billed charges,90% of total billed charges,120.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,200.1,58,,,percent of total billed charges,58% of total billed charges,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,293.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,70.28,310.5,
OMNICEF SUSP 125MG/5ML,2605091,CDM,637,RC,,,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,310.5,90,,,percent of total billed charges,90% of total billed charges,120.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,200.1,58,,,percent of total billed charges,58% of total billed charges,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,293.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,70.28,310.5,
ADVAIR (FLUTIC/SALMETEROL)MDI INH 100-50,2605143,CDM,250,RC,,,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,310.5,90,,,percent of total billed charges,90% of total billed charges,120.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,200.1,58,,,percent of total billed charges,58% of total billed charges,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,293.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,70.28,310.5,
XALATAN (LATANOPROST) 0.005% EYE DROPS,2610004,CDM,637,RC,,,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,310.5,90,,,percent of total billed charges,90% of total billed charges,120.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,200.1,58,,,percent of total billed charges,58% of total billed charges,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,293.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,70.28,310.5,
"ALDOSTERONE, SERUM",3000001,CDM,301,RC,82088,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,40.75,100,,,fee schedule,Pays 100% Medicare OPPS,40.75,100,,,fee schedule,Pays 100% Medicare OPPS,40.75,100,,,fee schedule,Pays 100% Medicare OPPS,52.97,130,,,fee schedule,Pays 130% Medicare OPPS,61.69,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,41.56,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,64.15,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,40.75,100,,,fee schedule,Pays 100% Medicare OPPS,36.67,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,61.69,120.37,,,fee schedule,120.37% of custom fee schedule,40.75,100,,,fee schedule,Pays 100% Medicare OPPS,52.97,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,40.75,100,,,fee schedule,Pays 100% Medicare OPPS,36.67,310.5,
CULTURE HERPES,3000067,CDM,306,RC,87252,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,33.89,130,,,fee schedule,Pays 130% Medicare OPPS,33.46,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,26.59,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,34.8,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,23.46,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,33.46,120.37,,,fee schedule,120.37% of custom fee schedule,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,33.89,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,23.46,310.5,
3RD CULTURE VIRAL,3000075,CDM,306,RC,87252,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,33.89,130,,,fee schedule,Pays 130% Medicare OPPS,33.46,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,26.59,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,34.8,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,23.46,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,33.46,120.37,,,fee schedule,120.37% of custom fee schedule,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,33.89,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,23.46,310.5,
DNA BY FARR ASSAY,3000087,CDM,302,RC,86225,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,13.74,100,,,fee schedule,Pays 100% Medicare OPPS,13.74,100,,,fee schedule,Pays 100% Medicare OPPS,13.74,100,,,fee schedule,Pays 100% Medicare OPPS,17.86,130,,,fee schedule,Pays 130% Medicare OPPS,20.8,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.01,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,21.63,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,13.74,100,,,fee schedule,Pays 100% Medicare OPPS,12.36,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,20.8,120.37,,,fee schedule,120.37% of custom fee schedule,13.74,100,,,fee schedule,Pays 100% Medicare OPPS,17.86,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,13.74,100,,,fee schedule,Pays 100% Medicare OPPS,12.36,310.5,
INFLUENZA B VIRUS AB,3000173,CDM,302,RC,86710,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,13.55,100,,,fee schedule,Pays 100% Medicare OPPS,13.55,100,,,fee schedule,Pays 100% Medicare OPPS,13.55,100,,,fee schedule,Pays 100% Medicare OPPS,17.61,130,,,fee schedule,Pays 130% Medicare OPPS,20.52,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.82,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,21.34,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,13.55,100,,,fee schedule,Pays 100% Medicare OPPS,12.19,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,20.52,120.37,,,fee schedule,120.37% of custom fee schedule,13.55,100,,,fee schedule,Pays 100% Medicare OPPS,17.61,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,13.55,100,,,fee schedule,Pays 100% Medicare OPPS,12.19,310.5,
3RD GABAPENTIN,3000222,CDM,301,RC,80171,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,21.67,100,,,fee schedule,Pays 100% Medicare OPPS,21.67,100,,,fee schedule,Pays 100% Medicare OPPS,21.67,100,,,fee schedule,Pays 100% Medicare OPPS,28.17,130,,,fee schedule,Pays 130% Medicare OPPS,17.42,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.1,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,18.11,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,21.67,100,,,fee schedule,Pays 100% Medicare OPPS,19.5,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,17.42,120.37,,,fee schedule,120.37% of custom fee schedule,21.67,100,,,fee schedule,Pays 100% Medicare OPPS,28.17,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,21.67,100,,,fee schedule,Pays 100% Medicare OPPS,17.42,310.5,
Testing for presence of drug,3000299,CDM,301,RC,80307,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,80.78,130,,,fee schedule,Pays 130% Medicare OPPS,73.62,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,63.38,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,76.56,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,55.92,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,73.62,120.37,,,fee schedule,120.37% of custom fee schedule,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,80.78,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,55.92,310.5,
Testing for presence of drug,3000300,CDM,301,RC,80307,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,80.78,130,,,fee schedule,Pays 130% Medicare OPPS,73.62,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,63.38,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,76.56,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,55.92,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,73.62,120.37,,,fee schedule,120.37% of custom fee schedule,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,80.78,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,55.92,310.5,
VIRAL STUDIES,3000331,CDM,306,RC,87252,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,33.89,130,,,fee schedule,Pays 130% Medicare OPPS,33.46,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,26.59,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,34.8,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,23.46,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,33.46,120.37,,,fee schedule,120.37% of custom fee schedule,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,33.89,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,23.46,310.5,
D DIMER,3000567,CDM,305,RC,85379,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,13.23,130,,,fee schedule,Pays 130% Medicare OPPS,15.41,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,10.38,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,16.02,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,9.16,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,15.41,120.37,,,fee schedule,120.37% of custom fee schedule,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,13.23,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,9.16,310.5,
ALDOSTERONE/RENIN RATIO,3000673,CDM,301,RC,,,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,310.5,90,,,percent of total billed charges,90% of total billed charges,120.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,200.1,58,,,percent of total billed charges,58% of total billed charges,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,293.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,70.28,310.5,
3RD HISTAMINE RELEASE,3000801,CDM,305,RC,86343,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,12.46,100,,,fee schedule,Pays 100% Medicare OPPS,12.46,100,,,fee schedule,Pays 100% Medicare OPPS,12.46,100,,,fee schedule,Pays 100% Medicare OPPS,16.19,130,,,fee schedule,Pays 130% Medicare OPPS,18.86,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.7,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,19.62,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,12.46,100,,,fee schedule,Pays 100% Medicare OPPS,11.21,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,18.86,120.37,,,fee schedule,120.37% of custom fee schedule,12.46,100,,,fee schedule,Pays 100% Medicare OPPS,16.19,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,12.46,100,,,fee schedule,Pays 100% Medicare OPPS,11.21,310.5,
"Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)",3080051,CDM,301,RC,80051,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,7.01,100,,,fee schedule,Pays 100% Medicare OPPS,7.01,100,,,fee schedule,Pays 100% Medicare OPPS,7.01,100,,,fee schedule,Pays 100% Medicare OPPS,9.11,130,,,fee schedule,Pays 130% Medicare OPPS,10.62,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,7.15,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,11.04,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,7.01,100,,,fee schedule,Pays 100% Medicare OPPS,6.3,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,10.62,120.37,,,fee schedule,120.37% of custom fee schedule,7.01,100,,,fee schedule,Pays 100% Medicare OPPS,9.11,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,7.01,100,,,fee schedule,Pays 100% Medicare OPPS,6.3,310.5,
DHEA,3082626,CDM,301,RC,82626,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,25.27,100,,,fee schedule,Pays 100% Medicare OPPS,25.27,100,,,fee schedule,Pays 100% Medicare OPPS,25.27,100,,,fee schedule,Pays 100% Medicare OPPS,32.85,130,,,fee schedule,Pays 130% Medicare OPPS,38.25,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.77,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,39.78,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,25.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.74,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,38.25,120.37,,,fee schedule,120.37% of custom fee schedule,25.27,100,,,fee schedule,Pays 100% Medicare OPPS,32.85,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,25.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.74,310.5,
Blood test to measure an enzyme in the blood,3082627,CDM,301,RC,82627,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,22.23,100,,,fee schedule,Pays 100% Medicare OPPS,22.23,100,,,fee schedule,Pays 100% Medicare OPPS,22.23,100,,,fee schedule,Pays 100% Medicare OPPS,28.89,130,,,fee schedule,Pays 130% Medicare OPPS,33.66,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.67,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,35,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,22.23,100,,,fee schedule,Pays 100% Medicare OPPS,20,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,33.66,120.37,,,fee schedule,120.37% of custom fee schedule,22.23,100,,,fee schedule,Pays 100% Medicare OPPS,28.89,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,22.23,100,,,fee schedule,Pays 100% Medicare OPPS,20,310.5,
ELECTROPHORETIC TECHNIQUE,3082664,CDM,301,RC,82664,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,61.5,100,,,fee schedule,Pays 100% Medicare OPPS,61.5,100,,,fee schedule,Pays 100% Medicare OPPS,61.5,100,,,fee schedule,Pays 100% Medicare OPPS,79.95,130,,,fee schedule,Pays 130% Medicare OPPS,52,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.73,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,54.08,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,61.5,100,,,fee schedule,Pays 100% Medicare OPPS,55.35,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,52,120.37,,,fee schedule,120.37% of custom fee schedule,61.5,100,,,fee schedule,Pays 100% Medicare OPPS,79.95,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,61.5,100,,,fee schedule,Pays 100% Medicare OPPS,52,310.5,
"ESTRIOL, TOTAL",3082677,CDM,301,RC,82677,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,24.18,100,,,fee schedule,Pays 100% Medicare OPPS,24.18,100,,,fee schedule,Pays 100% Medicare OPPS,24.18,100,,,fee schedule,Pays 100% Medicare OPPS,31.43,130,,,fee schedule,Pays 130% Medicare OPPS,36.6,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,24.66,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,38.07,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,24.18,100,,,fee schedule,Pays 100% Medicare OPPS,21.76,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,36.6,120.37,,,fee schedule,120.37% of custom fee schedule,24.18,100,,,fee schedule,Pays 100% Medicare OPPS,31.43,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,24.18,100,,,fee schedule,Pays 100% Medicare OPPS,21.76,310.5,
GLUCAGON,3082943,CDM,301,RC,82943,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,14.29,100,,,fee schedule,Pays 100% Medicare OPPS,14.29,100,,,fee schedule,Pays 100% Medicare OPPS,14.29,100,,,fee schedule,Pays 100% Medicare OPPS,18.57,130,,,fee schedule,Pays 130% Medicare OPPS,21.63,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.57,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,22.49,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,14.29,100,,,fee schedule,Pays 100% Medicare OPPS,12.86,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,21.63,120.37,,,fee schedule,120.37% of custom fee schedule,14.29,100,,,fee schedule,Pays 100% Medicare OPPS,18.57,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,14.29,100,,,fee schedule,Pays 100% Medicare OPPS,12.86,310.5,
3RD PROTEIN C (ANTIGEN) LEVEL,3085302,CDM,305,RC,85302,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,12.01,100,,,fee schedule,Pays 100% Medicare OPPS,12.01,100,,,fee schedule,Pays 100% Medicare OPPS,12.01,100,,,fee schedule,Pays 100% Medicare OPPS,15.61,130,,,fee schedule,Pays 130% Medicare OPPS,18.2,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.25,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,18.93,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,12.01,100,,,fee schedule,Pays 100% Medicare OPPS,10.8,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,18.2,120.37,,,fee schedule,120.37% of custom fee schedule,12.01,100,,,fee schedule,Pays 100% Medicare OPPS,15.61,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,12.01,100,,,fee schedule,Pays 100% Medicare OPPS,10.8,310.5,
3RD PROTEIN C (ACTIVITY) LEVEL,3085303,CDM,305,RC,85303,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,13.84,100,,,fee schedule,Pays 100% Medicare OPPS,13.84,100,,,fee schedule,Pays 100% Medicare OPPS,13.84,100,,,fee schedule,Pays 100% Medicare OPPS,17.99,130,,,fee schedule,Pays 130% Medicare OPPS,20.93,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.11,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,21.77,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,13.84,100,,,fee schedule,Pays 100% Medicare OPPS,12.45,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,20.93,120.37,,,fee schedule,120.37% of custom fee schedule,13.84,100,,,fee schedule,Pays 100% Medicare OPPS,17.99,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,13.84,100,,,fee schedule,Pays 100% Medicare OPPS,12.45,310.5,
PROTEIN S (ANTIGEN) LEVEL,3085305,CDM,305,RC,85305,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,11.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.61,100,,,fee schedule,Pays 100% Medicare OPPS,15.09,130,,,fee schedule,Pays 130% Medicare OPPS,17.55,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.84,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,18.25,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,11.61,100,,,fee schedule,Pays 100% Medicare OPPS,10.44,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,17.55,120.37,,,fee schedule,120.37% of custom fee schedule,11.61,100,,,fee schedule,Pays 100% Medicare OPPS,15.09,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,11.61,100,,,fee schedule,Pays 100% Medicare OPPS,10.44,310.5,
3RD PROTEIN S (ACTIVITY) LEVEL,3085306,CDM,305,RC,85306,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,15.32,100,,,fee schedule,Pays 100% Medicare OPPS,15.32,100,,,fee schedule,Pays 100% Medicare OPPS,15.32,100,,,fee schedule,Pays 100% Medicare OPPS,19.91,130,,,fee schedule,Pays 130% Medicare OPPS,23.2,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.62,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,24.12,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,15.32,100,,,fee schedule,Pays 100% Medicare OPPS,13.78,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,23.2,120.37,,,fee schedule,120.37% of custom fee schedule,15.32,100,,,fee schedule,Pays 100% Medicare OPPS,19.91,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,15.32,100,,,fee schedule,Pays 100% Medicare OPPS,13.78,310.5,
.D DIMER,3085379,CDM,305,RC,85379,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,13.23,130,,,fee schedule,Pays 130% Medicare OPPS,15.41,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,10.38,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,16.02,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,9.16,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,15.41,120.37,,,fee schedule,120.37% of custom fee schedule,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,13.23,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,9.16,310.5,
THROMBIN TIME,3085670,CDM,305,RC,85670,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,5.77,100,,,fee schedule,Pays 100% Medicare OPPS,5.77,100,,,fee schedule,Pays 100% Medicare OPPS,5.77,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,130,,,fee schedule,Pays 130% Medicare OPPS,8.74,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.88,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,9.09,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,5.77,100,,,fee schedule,Pays 100% Medicare OPPS,5.19,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,8.74,120.37,,,fee schedule,120.37% of custom fee schedule,5.77,100,,,fee schedule,Pays 100% Medicare OPPS,7.5,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,5.77,100,,,fee schedule,Pays 100% Medicare OPPS,5.19,310.5,
Blood test to monitor breast cancer,3086300,CDM,302,RC,86300,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,27.05,130,,,fee schedule,Pays 130% Medicare OPPS,31.49,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,21.22,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,32.75,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,18.72,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,31.49,120.37,,,fee schedule,120.37% of custom fee schedule,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,27.05,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,18.72,310.5,
ANTI LKM,3086376,CDM,302,RC,86376,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,14.55,100,,,fee schedule,Pays 100% Medicare OPPS,14.55,100,,,fee schedule,Pays 100% Medicare OPPS,14.55,100,,,fee schedule,Pays 100% Medicare OPPS,18.91,130,,,fee schedule,Pays 130% Medicare OPPS,22.03,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.84,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,22.91,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,14.55,100,,,fee schedule,Pays 100% Medicare OPPS,13.09,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,22.03,120.37,,,fee schedule,120.37% of custom fee schedule,14.55,100,,,fee schedule,Pays 100% Medicare OPPS,18.91,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,14.55,100,,,fee schedule,Pays 100% Medicare OPPS,13.09,310.5,
DIPHTHERIA ANTIBODIES,3086648,CDM,302,RC,86648,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,15.21,100,,,fee schedule,Pays 100% Medicare OPPS,15.21,100,,,fee schedule,Pays 100% Medicare OPPS,15.21,100,,,fee schedule,Pays 100% Medicare OPPS,19.77,130,,,fee schedule,Pays 130% Medicare OPPS,23.03,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.51,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,23.95,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,15.21,100,,,fee schedule,Pays 100% Medicare OPPS,13.68,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,23.03,120.37,,,fee schedule,120.37% of custom fee schedule,15.21,100,,,fee schedule,Pays 100% Medicare OPPS,19.77,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,15.21,100,,,fee schedule,Pays 100% Medicare OPPS,13.68,310.5,
H FLU b ANTIBODIES IgG,3086684,CDM,300,RC,86684,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,15.84,100,,,fee schedule,Pays 100% Medicare OPPS,15.84,100,,,fee schedule,Pays 100% Medicare OPPS,15.84,100,,,fee schedule,Pays 100% Medicare OPPS,20.59,130,,,fee schedule,Pays 130% Medicare OPPS,23.99,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.15,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,24.95,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,15.84,100,,,fee schedule,Pays 100% Medicare OPPS,14.25,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,23.99,120.37,,,fee schedule,120.37% of custom fee schedule,15.84,100,,,fee schedule,Pays 100% Medicare OPPS,20.59,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,15.84,100,,,fee schedule,Pays 100% Medicare OPPS,14.25,310.5,
INFLUENZA A VIRUS AB,3086710,CDM,302,RC,86710,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,13.55,100,,,fee schedule,Pays 100% Medicare OPPS,13.55,100,,,fee schedule,Pays 100% Medicare OPPS,13.55,100,,,fee schedule,Pays 100% Medicare OPPS,17.61,130,,,fee schedule,Pays 130% Medicare OPPS,20.52,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.82,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,21.34,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,13.55,100,,,fee schedule,Pays 100% Medicare OPPS,12.19,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,20.52,120.37,,,fee schedule,120.37% of custom fee schedule,13.55,100,,,fee schedule,Pays 100% Medicare OPPS,17.61,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,13.55,100,,,fee schedule,Pays 100% Medicare OPPS,12.19,310.5,
3RD TOXOPLASMOSIS IgM,3086778,CDM,302,RC,86778,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,14.41,100,,,fee schedule,Pays 100% Medicare OPPS,14.41,100,,,fee schedule,Pays 100% Medicare OPPS,14.41,100,,,fee schedule,Pays 100% Medicare OPPS,18.73,130,,,fee schedule,Pays 130% Medicare OPPS,21.8,120.37,,,fee schedule,120.37% of custom fee schedule,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.69,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,22.67,125.18,,,fee schedule,125.18% of custom fee schedule,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,14.41,100,,,fee schedule,Pays 100% Medicare OPPS,12.96,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,21.8,120.37,,,fee schedule,120.37% of custom fee schedule,14.41,100,,,fee schedule,Pays 100% Medicare OPPS,18.73,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,14.41,100,,,fee schedule,Pays 100% Medicare OPPS,12.96,310.5,
Therapy for speech or hearing,5292507,CDM,440,RC,92507,HCPCS,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,74.2,100,,,fee schedule,Pays 100% Medicare OPPS,74.2,100,,,fee schedule,Pays 100% Medicare OPPS,74.2,100,,,fee schedule,Pays 100% Medicare OPPS,95.54,130,,,fee schedule,Pays 130% Medicare OPPS,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,75.68,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,120.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,74.2,100,,,fee schedule,Pays 100% Medicare OPPS,66.78,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,73.49,100,,,fee schedule,Pays 100% Medicare OPPS,95.54,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,74.2,100,,,fee schedule,Pays 100% Medicare OPPS,66.78,310.5,
LUMBO SACRAL SUPPORT LG,7905776,CDM,274,RC,L0625,HCPCS,Both,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,49.46,100,,,fee schedule,Pays 100% Medicare OPPS,49.46,100,,,fee schedule,Pays 100% Medicare OPPS,49.46,100,,,fee schedule,Pays 100% Medicare OPPS,67.61,130,,,fee schedule,Pays 130% Medicare OPPS,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,50.45,102,,,fee schedule,Pays 102% Medicare OPPS,310.5,90,,,percent of total billed charges,90% of total billed charges,120.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,49.46,100,,,fee schedule,Pays 100% Medicare OPPS,44.51,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,52.01,100,,,fee schedule,Pays 100% Medicare OPPS,67.61,130,,,fee schedule,Pays 130% Medicare OPPS,293.25,85,,,percent of total billed charges,85% of total billed charges,49.46,100,,,fee schedule,Pays 100% Medicare OPPS,44.51,310.5,
PLEUR-EVAC,7905964,CDM,270,RC,,,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,310.5,90,,,percent of total billed charges,90% of total billed charges,120.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,310.5,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,293.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,70.28,310.5,
GASTROSTOMY TUBE CUBBY 35-2030,7950189,CDM,270,RC,,,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,310.5,90,,,percent of total billed charges,90% of total billed charges,120.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,310.5,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,293.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,70.28,310.5,
GASTROSTOMY TUBE CUBBY 35-2035,7950190,CDM,270,RC,,,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,310.5,90,,,percent of total billed charges,90% of total billed charges,120.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,310.5,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,293.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,70.28,310.5,
GASTROSTOMY TUBE CUBBY 35-2040,7950191,CDM,270,RC,,,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,310.5,90,,,percent of total billed charges,90% of total billed charges,120.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,310.5,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,293.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,70.28,310.5,
GASTROSTOMY TUBE CUBBY 35-2425,7950192,CDM,270,RC,,,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,310.5,90,,,percent of total billed charges,90% of total billed charges,120.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,310.5,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,293.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,70.28,310.5,
GASTROSTOMY TUBE CUBBY 35-2430,7950193,CDM,270,RC,,,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,310.5,90,,,percent of total billed charges,90% of total billed charges,120.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,310.5,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,293.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,70.28,310.5,
GASTROSTOMY TUBE CUBBY 35-2025,7950194,CDM,270,RC,,,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,310.5,90,,,percent of total billed charges,90% of total billed charges,120.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,310.5,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,293.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,70.28,310.5,
GASTROSTOMY TUBE CUBBY 35-2435,7950195,CDM,270,RC,,,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,310.5,90,,,percent of total billed charges,90% of total billed charges,120.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,310.5,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,293.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,70.28,310.5,
GASTROSTOMY TUBE CUBBY 35-2440,7950197,CDM,270,RC,,,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,310.5,90,,,percent of total billed charges,90% of total billed charges,120.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,310.5,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,293.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,70.28,310.5,
GASTROSTOMY TUBE CUBBY 35-2445,7950200,CDM,270,RC,,,Outpatient,,,345,276,,293.25,85,,,percent of total billed charges,85% of total billed charges,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,86.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,194.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,310.5,90,,,percent of total billed charges,90% of total billed charges,120.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,237.02,68.7,,,percent of total billed charges,68.7% of total billed charges,276,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,310.5,90,,,fee schedule,Pays 90% Medicare OPPS,200.1,58,,,percent of total billed charges,58% of total billed charges,70.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,293.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,70.28,310.5,
ROMAZICON (FLUMAZENIL) INJ 0.1MG,2601388,CDM,250,RC,,,Outpatient,,,350,280,,297.5,85,,,percent of total billed charges,85% of total billed charges,87.5,100,,,fee schedule,Pays 100% Medicare OPPS,87.5,100,,,fee schedule,Pays 100% Medicare OPPS,87.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,71.3,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,197.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,197.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,197.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,197.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,315,90,,,percent of total billed charges,90% of total billed charges,122.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,240.45,68.7,,,percent of total billed charges,68.7% of total billed charges,280,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,315,90,,,fee schedule,Pays 90% Medicare OPPS,203,58,,,percent of total billed charges,58% of total billed charges,71.3,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,297.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,71.3,315,
PREMARIN (ESTROGENS CONJ) INJ 25MG,2605084,CDM,636,RC,J1410,HCPCS,Both,,,350,280,,297.5,85,,,percent of total billed charges,85% of total billed charges,355.49,100,,,fee schedule,Pays 100% Medicare OPPS,355.49,100,,,fee schedule,Pays 100% Medicare OPPS,355.49,100,,,fee schedule,Pays 100% Medicare OPPS,484.22,130,,,fee schedule,Pays 130% Medicare OPPS,427.9,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,362.59,102,,,fee schedule,Pays 102% Medicare OPPS,315,90,,,percent of total billed charges,90% of total billed charges,445,125.18,,,fee schedule,125.18% of custom fee schedule,240.45,68.7,,,percent of total billed charges,68.7% of total billed charges,280,80,,,percent of total billed charges,80 percent of total billed charges,355.49,100,,,fee schedule,Pays 100% Medicare OPPS,319.94,90,,,fee schedule,Pays 90% Medicare OPPS,203,58,,,percent of total billed charges,58% of total billed charges,427.9,120.37,,,fee schedule,120.37% of custom fee schedule,372.48,100,,,fee schedule,Pays 100% Medicare OPPS,484.22,130,,,fee schedule,Pays 130% Medicare OPPS,297.5,85,,,percent of total billed charges,85% of total billed charges,355.49,100,,,fee schedule,Pays 100% Medicare OPPS,203,484.22,
TESTOSTERONE TOTAL LEVEL,3000298,CDM,301,RC,84403,HCPCS,Outpatient,,,350,280,,297.5,85,,,percent of total billed charges,85% of total billed charges,25.81,100,,,fee schedule,Pays 100% Medicare OPPS,25.81,100,,,fee schedule,Pays 100% Medicare OPPS,25.81,100,,,fee schedule,Pays 100% Medicare OPPS,33.55,130,,,fee schedule,Pays 130% Medicare OPPS,39.08,120.37,,,fee schedule,120.37% of custom fee schedule,197.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,197.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,197.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,197.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,26.32,102,,,fee schedule,Pays 102% Medicare OPPS,315,90,,,percent of total billed charges,90% of total billed charges,40.65,125.18,,,fee schedule,125.18% of custom fee schedule,240.45,68.7,,,percent of total billed charges,68.7% of total billed charges,280,80,,,percent of total billed charges,80 percent of total billed charges,25.81,100,,,fee schedule,Pays 100% Medicare OPPS,23.22,90,,,fee schedule,Pays 90% Medicare OPPS,203,58,,,percent of total billed charges,58% of total billed charges,39.08,120.37,,,fee schedule,120.37% of custom fee schedule,25.81,100,,,fee schedule,Pays 100% Medicare OPPS,33.55,130,,,fee schedule,Pays 130% Medicare OPPS,297.5,85,,,percent of total billed charges,85% of total billed charges,25.81,100,,,fee schedule,Pays 100% Medicare OPPS,23.22,315,
XR SPINE SINGLE VIEW,4072020,CDM,320,RC,72020,HCPCS,Outpatient,,,350,280,,297.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,71.3,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,197.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,197.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,197.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,196.7,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,315,90,,,percent of total billed charges,90% of total billed charges,122.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,240.45,68.7,,,percent of total billed charges,68.7% of total billed charges,280,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,203,58,,,percent of total billed charges,58% of total billed charges,71.3,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,297.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,315,
"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",4376091,CDM,401,RC,77066,HCPCS,Outpatient,,,350,280,,297.5,85,,,percent of total billed charges,85% of total billed charges,101.49,100,,,fee schedule,Pays 100% Medicare OPPS,101.49,100,,,fee schedule,Pays 100% Medicare OPPS,101.49,100,,,fee schedule,Pays 100% Medicare OPPS,129.68,130,,,fee schedule,Pays 130% Medicare OPPS,71.3,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,197.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,197.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,197.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,196.7,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.52,102,,,fee schedule,Pays 102% Medicare OPPS,315,90,,,percent of total billed charges,90% of total billed charges,122.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,240.45,68.7,,,percent of total billed charges,68.7% of total billed charges,280,80,,,percent of total billed charges,80 percent of total billed charges,101.49,100,,,fee schedule,Pays 100% Medicare OPPS,91.34,90,,,fee schedule,Pays 90% Medicare OPPS,203,58,,,percent of total billed charges,58% of total billed charges,71.3,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,99.75,100,,,fee schedule,Pays 100% Medicare OPPS,129.68,130,,,fee schedule,Pays 130% Medicare OPPS,297.5,85,,,percent of total billed charges,85% of total billed charges,101.49,100,,,fee schedule,Pays 100% Medicare OPPS,71.3,315,
LINEAR STAPLER RELOADABLE TX60G,7950161,CDM,272,RC,,,Outpatient,,,355,284,,301.75,85,,,percent of total billed charges,85% of total billed charges,88.75,100,,,fee schedule,Pays 100% Medicare OPPS,88.75,100,,,fee schedule,Pays 100% Medicare OPPS,88.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,72.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,200.58,56.5,,,percent of total billed charges,56.5 percent of total billed charges,200.58,56.5,,,percent of total billed charges,56.5 percent of total billed charges,200.58,56.5,,,percent of total billed charges,56.5 percent of total billed charges,200.58,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,319.5,90,,,percent of total billed charges,90% of total billed charges,124.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,243.89,68.7,,,percent of total billed charges,68.7% of total billed charges,284,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,319.5,90,,,fee schedule,Pays 90% Medicare OPPS,205.9,58,,,percent of total billed charges,58% of total billed charges,72.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,301.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,72.31,319.5,
LINEAR STAPLER RELOADABLE TX60B,7950170,CDM,272,RC,,,Outpatient,,,355,284,,301.75,85,,,percent of total billed charges,85% of total billed charges,88.75,100,,,fee schedule,Pays 100% Medicare OPPS,88.75,100,,,fee schedule,Pays 100% Medicare OPPS,88.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,72.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,200.58,56.5,,,percent of total billed charges,56.5 percent of total billed charges,200.58,56.5,,,percent of total billed charges,56.5 percent of total billed charges,200.58,56.5,,,percent of total billed charges,56.5 percent of total billed charges,200.58,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,319.5,90,,,percent of total billed charges,90% of total billed charges,124.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,243.89,68.7,,,percent of total billed charges,68.7% of total billed charges,284,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,319.5,90,,,fee schedule,Pays 90% Medicare OPPS,205.9,58,,,percent of total billed charges,58% of total billed charges,72.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,301.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,72.31,319.5,
SINUS BALLOON INFLATION DEVICE BID30,1570757,CDM,272,RC,,,Outpatient,,,360,288,,306,85,,,percent of total billed charges,85% of total billed charges,90,100,,,fee schedule,Pays 100% Medicare OPPS,90,100,,,fee schedule,Pays 100% Medicare OPPS,90,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,73.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,203.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,203.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,203.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,203.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,324,90,,,percent of total billed charges,90% of total billed charges,126,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,247.32,68.7,,,percent of total billed charges,68.7% of total billed charges,288,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,324,90,,,fee schedule,Pays 90% Medicare OPPS,208.8,58,,,percent of total billed charges,58% of total billed charges,73.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,306,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,73.33,324,
REMOVAL FOREIGN BODY FM EXTERNAL AUDITOR,2069200,CDM,450,RC,69200,HCPCS,Outpatient,,,360,288,,306,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,73.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,203.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,203.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,203.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,203.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,324,90,,,percent of total billed charges,90% of total billed charges,126,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,247.32,68.7,,,percent of total billed charges,68.7% of total billed charges,288,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,208.8,58,,,percent of total billed charges,58% of total billed charges,73.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,306,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,73.33,324,
SEREVENT (SALMETEROL DISK) INH,2602234,CDM,250,RC,,,Outpatient,,,360,288,,306,85,,,percent of total billed charges,85% of total billed charges,90,100,,,fee schedule,Pays 100% Medicare OPPS,90,100,,,fee schedule,Pays 100% Medicare OPPS,90,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,73.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,203.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,203.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,203.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,203.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,324,90,,,percent of total billed charges,90% of total billed charges,126,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,247.32,68.7,,,percent of total billed charges,68.7% of total billed charges,288,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,324,90,,,fee schedule,Pays 90% Medicare OPPS,208.8,58,,,percent of total billed charges,58% of total billed charges,73.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,306,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,73.33,324,
CATH KIT CENTRAL VENOUS AK-12703-CDC,7905499,CDM,270,RC,,,Outpatient,,,360,288,,306,85,,,percent of total billed charges,85% of total billed charges,90,100,,,fee schedule,Pays 100% Medicare OPPS,90,100,,,fee schedule,Pays 100% Medicare OPPS,90,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,73.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,203.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,203.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,203.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,203.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,324,90,,,percent of total billed charges,90% of total billed charges,126,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,247.32,68.7,,,percent of total billed charges,68.7% of total billed charges,288,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,324,90,,,fee schedule,Pays 90% Medicare OPPS,208.8,58,,,percent of total billed charges,58% of total billed charges,73.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,306,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,73.33,324,
Single view,407101,CDM,324,RC,71045,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,74.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,205.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,127.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.38,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,74.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.38,328.5,
ROCEPHIN INJ (CEFTRIAXONE NA) 2GM,2601062,CDM,636,RC,J0696,HCPCS,Both,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,91.25,100,,,fee schedule,Pays 100% Medicare OPPS,91.25,100,,,fee schedule,Pays 100% Medicare OPPS,91.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.6,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,328.5,90,,,percent of total billed charges,90% of total billed charges,0.63,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,328.5,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,0.6,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,310.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.6,328.5,
CLOZAPINE,3000056,CDM,301,RC,80299,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.01,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,18.95,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,328.5,
CO2 URINE 24 HOUR,3000058,CDM,300,RC,82374,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,4.88,100,,,fee schedule,Pays 100% Medicare OPPS,4.88,100,,,fee schedule,Pays 100% Medicare OPPS,4.88,100,,,fee schedule,Pays 100% Medicare OPPS,6.34,130,,,fee schedule,Pays 130% Medicare OPPS,7.4,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4.97,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,7.7,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,4.88,100,,,fee schedule,Pays 100% Medicare OPPS,4.39,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,7.4,120.37,,,fee schedule,120.37% of custom fee schedule,4.88,100,,,fee schedule,Pays 100% Medicare OPPS,6.34,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,4.88,100,,,fee schedule,Pays 100% Medicare OPPS,4.39,328.5,
DARVON LEVEL,3000082,CDM,301,RC,80367,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,74.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,328.5,90,,,percent of total billed charges,90% of total billed charges,127.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,211.7,58,,,percent of total billed charges,58% of total billed charges,74.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,310.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,74.35,328.5,
MEXILETINE LEVEL,3000199,CDM,301,RC,80299,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.01,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,18.95,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,328.5,
MUMPS VIRUS IGM ANTIBODY,3000217,CDM,302,RC,86735,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,13.05,100,,,fee schedule,Pays 100% Medicare OPPS,13.05,100,,,fee schedule,Pays 100% Medicare OPPS,13.05,100,,,fee schedule,Pays 100% Medicare OPPS,16.96,130,,,fee schedule,Pays 130% Medicare OPPS,19.75,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.31,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,20.54,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,13.05,100,,,fee schedule,Pays 100% Medicare OPPS,11.74,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,19.75,120.37,,,fee schedule,120.37% of custom fee schedule,13.05,100,,,fee schedule,Pays 100% Medicare OPPS,16.96,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,13.05,100,,,fee schedule,Pays 100% Medicare OPPS,11.74,328.5,
SACCHAROMYCES CEREVIS IgG,3000277,CDM,300,RC,86671,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,12.25,100,,,fee schedule,Pays 100% Medicare OPPS,12.25,100,,,fee schedule,Pays 100% Medicare OPPS,12.25,100,,,fee schedule,Pays 100% Medicare OPPS,15.92,130,,,fee schedule,Pays 130% Medicare OPPS,18.56,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.49,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,19.3,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,12.25,100,,,fee schedule,Pays 100% Medicare OPPS,11.02,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,18.56,120.37,,,fee schedule,120.37% of custom fee schedule,12.25,100,,,fee schedule,Pays 100% Medicare OPPS,15.92,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,12.25,100,,,fee schedule,Pays 100% Medicare OPPS,11.02,328.5,
URINE FOR WATSON SCHWARTZ,3000326,CDM,301,RC,84110,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,8.44,100,,,fee schedule,Pays 100% Medicare OPPS,8.44,100,,,fee schedule,Pays 100% Medicare OPPS,8.44,100,,,fee schedule,Pays 100% Medicare OPPS,10.97,130,,,fee schedule,Pays 130% Medicare OPPS,12.78,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.6,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,13.29,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,8.44,100,,,fee schedule,Pays 100% Medicare OPPS,7.59,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,12.78,120.37,,,fee schedule,120.37% of custom fee schedule,8.44,100,,,fee schedule,Pays 100% Medicare OPPS,10.97,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,8.44,100,,,fee schedule,Pays 100% Medicare OPPS,7.59,328.5,
METANEPHRINES RANDON UA,3000371,CDM,301,RC,83835,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,16.94,100,,,fee schedule,Pays 100% Medicare OPPS,16.94,100,,,fee schedule,Pays 100% Medicare OPPS,16.94,100,,,fee schedule,Pays 100% Medicare OPPS,22.02,130,,,fee schedule,Pays 130% Medicare OPPS,25.64,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.27,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,26.66,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,16.94,100,,,fee schedule,Pays 100% Medicare OPPS,15.24,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,25.64,120.37,,,fee schedule,120.37% of custom fee schedule,16.94,100,,,fee schedule,Pays 100% Medicare OPPS,22.02,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,16.94,100,,,fee schedule,Pays 100% Medicare OPPS,15.24,328.5,
THYROTROPIN RECPTOR AB,3000595,CDM,301,RC,83519,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,23.92,130,,,fee schedule,Pays 130% Medicare OPPS,20.45,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.76,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,21.27,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.55,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,20.45,120.37,,,fee schedule,120.37% of custom fee schedule,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,23.92,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.55,328.5,
DIGOXIN (LANOXIN) LEVEL,3080162,CDM,301,RC,80162,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,13.28,100,,,fee schedule,Pays 100% Medicare OPPS,13.28,100,,,fee schedule,Pays 100% Medicare OPPS,13.28,100,,,fee schedule,Pays 100% Medicare OPPS,17.26,130,,,fee schedule,Pays 130% Medicare OPPS,20.1,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.54,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,20.91,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,13.28,100,,,fee schedule,Pays 100% Medicare OPPS,11.95,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,20.1,120.37,,,fee schedule,120.37% of custom fee schedule,13.28,100,,,fee schedule,Pays 100% Medicare OPPS,17.26,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,13.28,100,,,fee schedule,Pays 100% Medicare OPPS,11.95,328.5,
PRONESTYL LEVEL,3080192,CDM,301,RC,80192,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,16.75,100,,,fee schedule,Pays 100% Medicare OPPS,16.75,100,,,fee schedule,Pays 100% Medicare OPPS,16.75,100,,,fee schedule,Pays 100% Medicare OPPS,21.77,130,,,fee schedule,Pays 130% Medicare OPPS,25.36,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.08,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,26.38,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,16.75,100,,,fee schedule,Pays 100% Medicare OPPS,15.07,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,25.36,120.37,,,fee schedule,120.37% of custom fee schedule,16.75,100,,,fee schedule,Pays 100% Medicare OPPS,21.77,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,16.75,100,,,fee schedule,Pays 100% Medicare OPPS,15.07,328.5,
VANCOMYCIN LEVEL,3080202,CDM,301,RC,80202,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,13.54,100,,,fee schedule,Pays 100% Medicare OPPS,13.54,100,,,fee schedule,Pays 100% Medicare OPPS,13.54,100,,,fee schedule,Pays 100% Medicare OPPS,17.6,130,,,fee schedule,Pays 130% Medicare OPPS,17.18,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.81,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,17.86,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,13.54,100,,,fee schedule,Pays 100% Medicare OPPS,12.18,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,17.18,120.37,,,fee schedule,120.37% of custom fee schedule,13.54,100,,,fee schedule,Pays 100% Medicare OPPS,17.6,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,13.54,100,,,fee schedule,Pays 100% Medicare OPPS,12.18,328.5,
VANCOMYCIN PEAK,3080203,CDM,301,RC,80202,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,13.54,100,,,fee schedule,Pays 100% Medicare OPPS,13.54,100,,,fee schedule,Pays 100% Medicare OPPS,13.54,100,,,fee schedule,Pays 100% Medicare OPPS,17.6,130,,,fee schedule,Pays 130% Medicare OPPS,17.18,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.81,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,17.86,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,13.54,100,,,fee schedule,Pays 100% Medicare OPPS,12.18,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,17.18,120.37,,,fee schedule,120.37% of custom fee schedule,13.54,100,,,fee schedule,Pays 100% Medicare OPPS,17.6,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,13.54,100,,,fee schedule,Pays 100% Medicare OPPS,12.18,328.5,
VANCOMYCIN TROUGH,3080204,CDM,301,RC,80202,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,13.54,100,,,fee schedule,Pays 100% Medicare OPPS,13.54,100,,,fee schedule,Pays 100% Medicare OPPS,13.54,100,,,fee schedule,Pays 100% Medicare OPPS,17.6,130,,,fee schedule,Pays 130% Medicare OPPS,17.18,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.81,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,17.86,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,13.54,100,,,fee schedule,Pays 100% Medicare OPPS,12.18,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,17.18,120.37,,,fee schedule,120.37% of custom fee schedule,13.54,100,,,fee schedule,Pays 100% Medicare OPPS,17.6,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,13.54,100,,,fee schedule,Pays 100% Medicare OPPS,12.18,328.5,
FIBRO TEST,3081596,CDM,301,RC,81596,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,72.19,100,,,fee schedule,Pays 100% Medicare OPPS,72.19,100,,,fee schedule,Pays 100% Medicare OPPS,72.19,100,,,fee schedule,Pays 100% Medicare OPPS,93.84,130,,,fee schedule,Pays 130% Medicare OPPS,69.51,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,73.63,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,72.29,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,72.19,100,,,fee schedule,Pays 100% Medicare OPPS,64.97,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,69.51,120.37,,,fee schedule,120.37% of custom fee schedule,72.19,100,,,fee schedule,Pays 100% Medicare OPPS,93.84,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,72.19,100,,,fee schedule,Pays 100% Medicare OPPS,64.97,328.5,
"ARSENIC, URINE 24 HR",3082175,CDM,301,RC,82175,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,18.97,100,,,fee schedule,Pays 100% Medicare OPPS,18.97,100,,,fee schedule,Pays 100% Medicare OPPS,18.97,100,,,fee schedule,Pays 100% Medicare OPPS,24.66,130,,,fee schedule,Pays 130% Medicare OPPS,28.72,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.34,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,29.87,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,18.97,100,,,fee schedule,Pays 100% Medicare OPPS,17.07,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,28.72,120.37,,,fee schedule,120.37% of custom fee schedule,18.97,100,,,fee schedule,Pays 100% Medicare OPPS,24.66,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,18.97,100,,,fee schedule,Pays 100% Medicare OPPS,17.07,328.5,
CEA,3082378,CDM,301,RC,82378,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,18.96,100,,,fee schedule,Pays 100% Medicare OPPS,18.96,100,,,fee schedule,Pays 100% Medicare OPPS,18.96,100,,,fee schedule,Pays 100% Medicare OPPS,24.64,130,,,fee schedule,Pays 130% Medicare OPPS,28.72,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.33,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,29.87,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,18.96,100,,,fee schedule,Pays 100% Medicare OPPS,17.06,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,28.72,120.37,,,fee schedule,120.37% of custom fee schedule,18.96,100,,,fee schedule,Pays 100% Medicare OPPS,24.64,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,18.96,100,,,fee schedule,Pays 100% Medicare OPPS,17.06,328.5,
ERYTHROPOIETIN,3082668,CDM,301,RC,82668,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,18.79,100,,,fee schedule,Pays 100% Medicare OPPS,18.79,100,,,fee schedule,Pays 100% Medicare OPPS,18.79,100,,,fee schedule,Pays 100% Medicare OPPS,24.42,130,,,fee schedule,Pays 130% Medicare OPPS,28.44,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.16,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,29.58,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,18.79,100,,,fee schedule,Pays 100% Medicare OPPS,16.91,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,28.44,120.37,,,fee schedule,120.37% of custom fee schedule,18.79,100,,,fee schedule,Pays 100% Medicare OPPS,24.42,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,18.79,100,,,fee schedule,Pays 100% Medicare OPPS,16.91,328.5,
FRUCTOSE SEMEN,3082757,CDM,301,RC,82757,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,17.34,100,,,fee schedule,Pays 100% Medicare OPPS,17.34,100,,,fee schedule,Pays 100% Medicare OPPS,17.34,100,,,fee schedule,Pays 100% Medicare OPPS,22.54,130,,,fee schedule,Pays 130% Medicare OPPS,26.26,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.68,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,27.31,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,17.34,100,,,fee schedule,Pays 100% Medicare OPPS,15.6,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,26.26,120.37,,,fee schedule,120.37% of custom fee schedule,17.34,100,,,fee schedule,Pays 100% Medicare OPPS,22.54,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,17.34,100,,,fee schedule,Pays 100% Medicare OPPS,15.6,328.5,
Test of hormone in the blood,3083002,CDM,301,RC,83002,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,18.52,100,,,fee schedule,Pays 100% Medicare OPPS,18.52,100,,,fee schedule,Pays 100% Medicare OPPS,18.52,100,,,fee schedule,Pays 100% Medicare OPPS,24.07,130,,,fee schedule,Pays 130% Medicare OPPS,28.03,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.89,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,29.15,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,18.52,100,,,fee schedule,Pays 100% Medicare OPPS,16.66,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,28.03,120.37,,,fee schedule,120.37% of custom fee schedule,18.52,100,,,fee schedule,Pays 100% Medicare OPPS,24.07,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,18.52,100,,,fee schedule,Pays 100% Medicare OPPS,16.66,328.5,
LIPOPROTEIN (a),3083695,CDM,301,RC,83695,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,14.32,100,,,fee schedule,Pays 100% Medicare OPPS,14.32,100,,,fee schedule,Pays 100% Medicare OPPS,14.32,100,,,fee schedule,Pays 100% Medicare OPPS,18.61,130,,,fee schedule,Pays 130% Medicare OPPS,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.6,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,20.38,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,14.32,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,14.32,100,,,fee schedule,Pays 100% Medicare OPPS,18.61,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,14.32,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,328.5,
METANEPHRINES 24 URINE,3083835,CDM,301,RC,83835,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,16.94,100,,,fee schedule,Pays 100% Medicare OPPS,16.94,100,,,fee schedule,Pays 100% Medicare OPPS,16.94,100,,,fee schedule,Pays 100% Medicare OPPS,22.02,130,,,fee schedule,Pays 130% Medicare OPPS,25.64,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.27,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,26.66,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,16.94,100,,,fee schedule,Pays 100% Medicare OPPS,15.24,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,25.64,120.37,,,fee schedule,120.37% of custom fee schedule,16.94,100,,,fee schedule,Pays 100% Medicare OPPS,22.02,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,16.94,100,,,fee schedule,Pays 100% Medicare OPPS,15.24,328.5,
PROGESTERONE LEVEL,3084144,CDM,301,RC,84144,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,20.86,100,,,fee schedule,Pays 100% Medicare OPPS,20.86,100,,,fee schedule,Pays 100% Medicare OPPS,20.86,100,,,fee schedule,Pays 100% Medicare OPPS,27.11,130,,,fee schedule,Pays 130% Medicare OPPS,30.83,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,21.27,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,32.06,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,20.86,100,,,fee schedule,Pays 100% Medicare OPPS,18.77,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,30.83,120.37,,,fee schedule,120.37% of custom fee schedule,20.86,100,,,fee schedule,Pays 100% Medicare OPPS,27.11,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,20.86,100,,,fee schedule,Pays 100% Medicare OPPS,18.77,328.5,
PLATELET ANTIBODIES,3086022,CDM,302,RC,86022,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,18.37,100,,,fee schedule,Pays 100% Medicare OPPS,18.37,100,,,fee schedule,Pays 100% Medicare OPPS,18.37,100,,,fee schedule,Pays 100% Medicare OPPS,23.88,130,,,fee schedule,Pays 130% Medicare OPPS,27.79,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.73,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,28.9,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,18.37,100,,,fee schedule,Pays 100% Medicare OPPS,16.53,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,27.79,120.37,,,fee schedule,120.37% of custom fee schedule,18.37,100,,,fee schedule,Pays 100% Medicare OPPS,23.88,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,18.37,100,,,fee schedule,Pays 100% Medicare OPPS,16.53,328.5,
CA 19-9 (COLON),3086301,CDM,302,RC,86301,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,27.05,130,,,fee schedule,Pays 130% Medicare OPPS,31.49,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,21.22,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,32.75,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,18.72,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,31.49,120.37,,,fee schedule,120.37% of custom fee schedule,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,27.05,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,18.72,328.5,
Blood test to monitor for cancer,3086304,CDM,302,RC,86304,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,27.05,130,,,fee schedule,Pays 130% Medicare OPPS,31.49,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,21.22,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,32.75,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,18.72,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,31.49,120.37,,,fee schedule,120.37% of custom fee schedule,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,27.05,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,18.72,328.5,
QUANTIFERON TB GOLD,3086480,CDM,301,RC,86480,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,61.98,100,,,fee schedule,Pays 100% Medicare OPPS,61.98,100,,,fee schedule,Pays 100% Medicare OPPS,61.98,100,,,fee schedule,Pays 100% Medicare OPPS,80.57,130,,,fee schedule,Pays 130% Medicare OPPS,93.8,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,63.21,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,97.55,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,61.98,100,,,fee schedule,Pays 100% Medicare OPPS,55.78,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,93.8,120.37,,,fee schedule,120.37% of custom fee schedule,61.98,100,,,fee schedule,Pays 100% Medicare OPPS,80.57,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,61.98,100,,,fee schedule,Pays 100% Medicare OPPS,55.78,328.5,
SACCHAROMYCES CEREVIS IgA,3086671,CDM,300,RC,86671,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,12.25,100,,,fee schedule,Pays 100% Medicare OPPS,12.25,100,,,fee schedule,Pays 100% Medicare OPPS,12.25,100,,,fee schedule,Pays 100% Medicare OPPS,15.92,130,,,fee schedule,Pays 130% Medicare OPPS,18.56,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.49,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,19.3,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,12.25,100,,,fee schedule,Pays 100% Medicare OPPS,11.02,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,18.56,120.37,,,fee schedule,120.37% of custom fee schedule,12.25,100,,,fee schedule,Pays 100% Medicare OPPS,15.92,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,12.25,100,,,fee schedule,Pays 100% Medicare OPPS,11.02,328.5,
Blood test indicating infection with Hepatitis A,3086708,CDM,302,RC,86708,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.1,130,,,fee schedule,Pays 130% Medicare OPPS,18.75,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.63,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,19.5,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,11.15,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,18.75,120.37,,,fee schedule,120.37% of custom fee schedule,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.1,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,12.39,100,,,fee schedule,Pays 100% Medicare OPPS,11.15,328.5,
MUMPS VIRUS IGG AB,3086735,CDM,302,RC,86735,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,13.05,100,,,fee schedule,Pays 100% Medicare OPPS,13.05,100,,,fee schedule,Pays 100% Medicare OPPS,13.05,100,,,fee schedule,Pays 100% Medicare OPPS,16.96,130,,,fee schedule,Pays 130% Medicare OPPS,19.75,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.31,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,20.54,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,13.05,100,,,fee schedule,Pays 100% Medicare OPPS,11.74,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,19.75,120.37,,,fee schedule,120.37% of custom fee schedule,13.05,100,,,fee schedule,Pays 100% Medicare OPPS,16.96,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,13.05,100,,,fee schedule,Pays 100% Medicare OPPS,11.74,328.5,
3RD HEPATITIS C BY RNA,3086804,CDM,302,RC,87522,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,130,,,fee schedule,Pays 130% Medicare OPPS,64.84,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,43.69,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,67.43,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,38.55,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,64.84,120.37,,,fee schedule,120.37% of custom fee schedule,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,38.55,328.5,
ROTA VIRUS STOOL,3087425,CDM,306,RC,87425,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,15.57,130,,,fee schedule,Pays 130% Medicare OPPS,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.21,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,18.88,125.18,,,fee schedule,125.18% of custom fee schedule,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,10.78,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,15.57,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,11.98,100,,,fee schedule,Pays 100% Medicare OPPS,10.78,328.5,
Single view,4071010,CDM,324,RC,71045,HCPCS,Outpatient,,,365,292,,310.25,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,74.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,206.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,205.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,328.5,90,,,percent of total billed charges,90% of total billed charges,127.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,250.76,68.7,,,percent of total billed charges,68.7% of total billed charges,292,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.38,90,,,fee schedule,Pays 90% Medicare OPPS,211.7,58,,,percent of total billed charges,58% of total billed charges,74.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,310.25,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.38,328.5,
MEFOXIN INJ (CEFOXITIN) 2GM,2601038,CDM,636,RC,J0694,HCPCS,Both,,,370,296,,314.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,6.39,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,333,90,,,percent of total billed charges,90% of total billed charges,6.65,125.18,,,fee schedule,125.18% of custom fee schedule,254.19,68.7,,,percent of total billed charges,68.7% of total billed charges,296,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,214.6,58,,,percent of total billed charges,58% of total billed charges,6.39,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,314.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6.39,333,
DURAGESIC (FENTANYL) PATCH 100MCG,2602612,CDM,250,RC,,,Outpatient,,,370,296,,314.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,75.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,333,90,,,percent of total billed charges,90% of total billed charges,129.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,254.19,68.7,,,percent of total billed charges,68.7% of total billed charges,296,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,214.6,58,,,percent of total billed charges,58% of total billed charges,75.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,314.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,75.37,333,
FLONASE (FLUTICASONE) NASAL SPRAY,2605031,CDM,637,RC,,,Outpatient,,,370,296,,314.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,75.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,333,90,,,percent of total billed charges,90% of total billed charges,129.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,254.19,68.7,,,percent of total billed charges,68.7% of total billed charges,296,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,214.6,58,,,percent of total billed charges,58% of total billed charges,75.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,314.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,75.37,333,
ANTI HU AUTO,3000013,CDM,301,RC,83520,HCPCS,Outpatient,,,370,296,,314.5,85,,,percent of total billed charges,85% of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,130,,,fee schedule,Pays 130% Medicare OPPS,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.61,102,,,fee schedule,Pays 102% Medicare OPPS,333,90,,,percent of total billed charges,90% of total billed charges,20.38,125.18,,,fee schedule,125.18% of custom fee schedule,254.19,68.7,,,percent of total billed charges,68.7% of total billed charges,296,80,,,percent of total billed charges,80 percent of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,15.54,90,,,fee schedule,Pays 90% Medicare OPPS,214.6,58,,,percent of total billed charges,58% of total billed charges,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,130,,,fee schedule,Pays 130% Medicare OPPS,314.5,85,,,percent of total billed charges,85% of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,15.54,333,
HALDOL LEVEL,3000141,CDM,301,RC,80173,HCPCS,Outpatient,,,370,296,,314.5,85,,,percent of total billed charges,85% of total billed charges,15.78,100,,,fee schedule,Pays 100% Medicare OPPS,15.78,100,,,fee schedule,Pays 100% Medicare OPPS,15.78,100,,,fee schedule,Pays 100% Medicare OPPS,20.51,130,,,fee schedule,Pays 130% Medicare OPPS,22.04,120.37,,,fee schedule,120.37% of custom fee schedule,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.09,102,,,fee schedule,Pays 102% Medicare OPPS,333,90,,,percent of total billed charges,90% of total billed charges,22.92,125.18,,,fee schedule,125.18% of custom fee schedule,254.19,68.7,,,percent of total billed charges,68.7% of total billed charges,296,80,,,percent of total billed charges,80 percent of total billed charges,15.78,100,,,fee schedule,Pays 100% Medicare OPPS,14.2,90,,,fee schedule,Pays 90% Medicare OPPS,214.6,58,,,percent of total billed charges,58% of total billed charges,22.04,120.37,,,fee schedule,120.37% of custom fee schedule,15.78,100,,,fee schedule,Pays 100% Medicare OPPS,20.51,130,,,fee schedule,Pays 130% Medicare OPPS,314.5,85,,,percent of total billed charges,85% of total billed charges,15.78,100,,,fee schedule,Pays 100% Medicare OPPS,14.2,333,
3RD LAMOTRIGINE LEVEL,3000184,CDM,301,RC,80299,HCPCS,Outpatient,,,370,296,,314.5,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.01,102,,,fee schedule,Pays 102% Medicare OPPS,333,90,,,percent of total billed charges,90% of total billed charges,18.95,125.18,,,fee schedule,125.18% of custom fee schedule,254.19,68.7,,,percent of total billed charges,68.7% of total billed charges,296,80,,,percent of total billed charges,80 percent of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,90,,,fee schedule,Pays 90% Medicare OPPS,214.6,58,,,percent of total billed charges,58% of total billed charges,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,314.5,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,333,
C2 COMPLEMENT,3000609,CDM,300,RC,86160,HCPCS,Outpatient,,,370,296,,314.5,85,,,percent of total billed charges,85% of total billed charges,12,100,,,fee schedule,Pays 100% Medicare OPPS,12,100,,,fee schedule,Pays 100% Medicare OPPS,12,100,,,fee schedule,Pays 100% Medicare OPPS,15.6,130,,,fee schedule,Pays 130% Medicare OPPS,18.18,120.37,,,fee schedule,120.37% of custom fee schedule,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.24,102,,,fee schedule,Pays 102% Medicare OPPS,333,90,,,percent of total billed charges,90% of total billed charges,18.9,125.18,,,fee schedule,125.18% of custom fee schedule,254.19,68.7,,,percent of total billed charges,68.7% of total billed charges,296,80,,,percent of total billed charges,80 percent of total billed charges,12,100,,,fee schedule,Pays 100% Medicare OPPS,10.8,90,,,fee schedule,Pays 90% Medicare OPPS,214.6,58,,,percent of total billed charges,58% of total billed charges,18.18,120.37,,,fee schedule,120.37% of custom fee schedule,12,100,,,fee schedule,Pays 100% Medicare OPPS,15.6,130,,,fee schedule,Pays 130% Medicare OPPS,314.5,85,,,percent of total billed charges,85% of total billed charges,12,100,,,fee schedule,Pays 100% Medicare OPPS,10.8,333,
.BARTONELLA HENSELAE IgM,3000640,CDM,302,RC,86611,HCPCS,Outpatient,,,370,296,,314.5,85,,,percent of total billed charges,85% of total billed charges,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,13.23,130,,,fee schedule,Pays 130% Medicare OPPS,15.41,120.37,,,fee schedule,120.37% of custom fee schedule,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,10.38,102,,,fee schedule,Pays 102% Medicare OPPS,333,90,,,percent of total billed charges,90% of total billed charges,16.02,125.18,,,fee schedule,125.18% of custom fee schedule,254.19,68.7,,,percent of total billed charges,68.7% of total billed charges,296,80,,,percent of total billed charges,80 percent of total billed charges,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,9.16,90,,,fee schedule,Pays 90% Medicare OPPS,214.6,58,,,percent of total billed charges,58% of total billed charges,15.41,120.37,,,fee schedule,120.37% of custom fee schedule,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,13.23,130,,,fee schedule,Pays 130% Medicare OPPS,314.5,85,,,percent of total billed charges,85% of total billed charges,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,9.16,333,
HALOPERIDOL LEVEL,3080173,CDM,301,RC,80173,HCPCS,Outpatient,,,370,296,,314.5,85,,,percent of total billed charges,85% of total billed charges,15.78,100,,,fee schedule,Pays 100% Medicare OPPS,15.78,100,,,fee schedule,Pays 100% Medicare OPPS,15.78,100,,,fee schedule,Pays 100% Medicare OPPS,20.51,130,,,fee schedule,Pays 130% Medicare OPPS,22.04,120.37,,,fee schedule,120.37% of custom fee schedule,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.09,102,,,fee schedule,Pays 102% Medicare OPPS,333,90,,,percent of total billed charges,90% of total billed charges,22.92,125.18,,,fee schedule,125.18% of custom fee schedule,254.19,68.7,,,percent of total billed charges,68.7% of total billed charges,296,80,,,percent of total billed charges,80 percent of total billed charges,15.78,100,,,fee schedule,Pays 100% Medicare OPPS,14.2,90,,,fee schedule,Pays 90% Medicare OPPS,214.6,58,,,percent of total billed charges,58% of total billed charges,22.04,120.37,,,fee schedule,120.37% of custom fee schedule,15.78,100,,,fee schedule,Pays 100% Medicare OPPS,20.51,130,,,fee schedule,Pays 130% Medicare OPPS,314.5,85,,,percent of total billed charges,85% of total billed charges,15.78,100,,,fee schedule,Pays 100% Medicare OPPS,14.2,333,
IMIPRAMIME LEVEL,3080174,CDM,301,RC,80335,HCPCS,Outpatient,,,370,296,,314.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.1,120.37,,,fee schedule,120.37% of custom fee schedule,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,333,90,,,percent of total billed charges,90% of total billed charges,28.18,125.18,,,fee schedule,125.18% of custom fee schedule,254.19,68.7,,,percent of total billed charges,68.7% of total billed charges,296,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,214.6,58,,,percent of total billed charges,58% of total billed charges,27.1,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,314.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.1,333,
.BARTONELLA HENSELAE IgG,3086611,CDM,302,RC,86611,HCPCS,Outpatient,,,370,296,,314.5,85,,,percent of total billed charges,85% of total billed charges,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,13.23,130,,,fee schedule,Pays 130% Medicare OPPS,15.41,120.37,,,fee schedule,120.37% of custom fee schedule,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,10.38,102,,,fee schedule,Pays 102% Medicare OPPS,333,90,,,percent of total billed charges,90% of total billed charges,16.02,125.18,,,fee schedule,125.18% of custom fee schedule,254.19,68.7,,,percent of total billed charges,68.7% of total billed charges,296,80,,,percent of total billed charges,80 percent of total billed charges,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,9.16,90,,,fee schedule,Pays 90% Medicare OPPS,214.6,58,,,percent of total billed charges,58% of total billed charges,15.41,120.37,,,fee schedule,120.37% of custom fee schedule,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,13.23,130,,,fee schedule,Pays 130% Medicare OPPS,314.5,85,,,percent of total billed charges,85% of total billed charges,10.18,100,,,fee schedule,Pays 100% Medicare OPPS,9.16,333,
Radiologic examination of the forearm,4000003,CDM,320,RC,73090,HCPCS,Outpatient,,,370,296,,314.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,75.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,207.94,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,333,90,,,percent of total billed charges,90% of total billed charges,129.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,254.19,68.7,,,percent of total billed charges,68.7% of total billed charges,296,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,214.6,58,,,percent of total billed charges,58% of total billed charges,75.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,314.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,333,
"Radiologic examination, elbow; 2 views",4000018,CDM,320,RC,73070,HCPCS,Outpatient,,,370,296,,314.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,75.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,207.94,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,333,90,,,percent of total billed charges,90% of total billed charges,129.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,254.19,68.7,,,percent of total billed charges,68.7% of total billed charges,296,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,214.6,58,,,percent of total billed charges,58% of total billed charges,75.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,314.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,333,
"Radiologic examination, elbow; 2 views",4000025,CDM,320,RC,73070,HCPCS,Outpatient,,,370,296,,314.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,75.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,207.94,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,333,90,,,percent of total billed charges,90% of total billed charges,129.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,254.19,68.7,,,percent of total billed charges,68.7% of total billed charges,296,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,214.6,58,,,percent of total billed charges,58% of total billed charges,75.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,314.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,333,
ETHIODOL,4000036,CDM,270,RC,,,Outpatient,,,370,296,,314.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,75.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,333,90,,,percent of total billed charges,90% of total billed charges,129.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,254.19,68.7,,,percent of total billed charges,68.7% of total billed charges,296,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,214.6,58,,,percent of total billed charges,58% of total billed charges,75.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,314.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,75.37,333,
XR KIDIGRAM,4070610,CDM,320,RC,76010,HCPCS,Outpatient,,,370,296,,314.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,75.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,207.94,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,333,90,,,percent of total billed charges,90% of total billed charges,129.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,254.19,68.7,,,percent of total billed charges,68.7% of total billed charges,296,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,214.6,58,,,percent of total billed charges,58% of total billed charges,75.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,314.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,333,
Radiologic examination of the collar bone,4072220,CDM,320,RC,73000,HCPCS,Outpatient,,,370,296,,314.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,75.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,207.94,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,333,90,,,percent of total billed charges,90% of total billed charges,129.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,254.19,68.7,,,percent of total billed charges,68.7% of total billed charges,296,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,214.6,58,,,percent of total billed charges,58% of total billed charges,75.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,314.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,333,
Radiologic examination of the collar bone,4073000,CDM,320,RC,73000,HCPCS,Outpatient,,,370,296,,314.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,75.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,207.94,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,333,90,,,percent of total billed charges,90% of total billed charges,129.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,254.19,68.7,,,percent of total billed charges,68.7% of total billed charges,296,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,214.6,58,,,percent of total billed charges,58% of total billed charges,75.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,314.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,333,
Radiologic examination of the forearm,4073090,CDM,320,RC,73090,HCPCS,Outpatient,,,370,296,,314.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,75.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,207.94,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,333,90,,,percent of total billed charges,90% of total billed charges,129.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,254.19,68.7,,,percent of total billed charges,68.7% of total billed charges,296,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,214.6,58,,,percent of total billed charges,58% of total billed charges,75.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,314.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,333,
XR KIDIGRAM,4076010,CDM,320,RC,76010,HCPCS,Outpatient,,,370,296,,314.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,75.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,209.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,207.94,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,333,90,,,percent of total billed charges,90% of total billed charges,129.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,254.19,68.7,,,percent of total billed charges,68.7% of total billed charges,296,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,214.6,58,,,percent of total billed charges,58% of total billed charges,75.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,314.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,333,
NM KINEVAC INJ 5 MCG,4500037,CDM,636,RC,J2805,HCPCS,Both,,,370,296,,314.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,75.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,333,90,,,percent of total billed charges,90% of total billed charges,129.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,254.19,68.7,,,percent of total billed charges,68.7% of total billed charges,296,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,214.6,58,,,percent of total billed charges,58% of total billed charges,75.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,314.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,75.37,333,
ADVAIR (FLUTIC/SALMETEROL)MDI INH 250-50,2605144,CDM,250,RC,,,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,337.5,90,,,percent of total billed charges,90% of total billed charges,131.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,217.5,58,,,percent of total billed charges,58% of total billed charges,76.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,318.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,76.39,337.5,
Blood test to monitor breast cancer,3000036,CDM,302,RC,86300,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,27.05,130,,,fee schedule,Pays 130% Medicare OPPS,31.49,120.37,,,fee schedule,120.37% of custom fee schedule,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,21.22,102,,,fee schedule,Pays 102% Medicare OPPS,337.5,90,,,percent of total billed charges,90% of total billed charges,32.75,125.18,,,fee schedule,125.18% of custom fee schedule,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,18.72,90,,,fee schedule,Pays 90% Medicare OPPS,217.5,58,,,percent of total billed charges,58% of total billed charges,31.49,120.37,,,fee schedule,120.37% of custom fee schedule,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,27.05,130,,,fee schedule,Pays 130% Medicare OPPS,318.75,85,,,percent of total billed charges,85% of total billed charges,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,18.72,337.5,
GD1a IgG,3000123,CDM,301,RC,83520,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,130,,,fee schedule,Pays 130% Medicare OPPS,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.61,102,,,fee schedule,Pays 102% Medicare OPPS,337.5,90,,,percent of total billed charges,90% of total billed charges,20.38,125.18,,,fee schedule,125.18% of custom fee schedule,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,15.54,90,,,fee schedule,Pays 90% Medicare OPPS,217.5,58,,,percent of total billed charges,58% of total billed charges,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,130,,,fee schedule,Pays 130% Medicare OPPS,318.75,85,,,percent of total billed charges,85% of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,15.54,337.5,
3RD KAPPA/LAMBDA CHAINS URINE,3000165,CDM,302,RC,83883,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,13.6,100,,,fee schedule,Pays 100% Medicare OPPS,13.6,100,,,fee schedule,Pays 100% Medicare OPPS,13.6,100,,,fee schedule,Pays 100% Medicare OPPS,17.68,130,,,fee schedule,Pays 130% Medicare OPPS,20.58,120.37,,,fee schedule,120.37% of custom fee schedule,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.87,102,,,fee schedule,Pays 102% Medicare OPPS,337.5,90,,,percent of total billed charges,90% of total billed charges,21.41,125.18,,,fee schedule,125.18% of custom fee schedule,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,13.6,100,,,fee schedule,Pays 100% Medicare OPPS,12.24,90,,,fee schedule,Pays 90% Medicare OPPS,217.5,58,,,percent of total billed charges,58% of total billed charges,20.58,120.37,,,fee schedule,120.37% of custom fee schedule,13.6,100,,,fee schedule,Pays 100% Medicare OPPS,17.68,130,,,fee schedule,Pays 130% Medicare OPPS,318.75,85,,,percent of total billed charges,85% of total billed charges,13.6,100,,,fee schedule,Pays 100% Medicare OPPS,12.24,337.5,
IMMUNOFIXATION URINE+UPEP,3000167,CDM,302,RC,84166,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,17.82,100,,,fee schedule,Pays 100% Medicare OPPS,17.82,100,,,fee schedule,Pays 100% Medicare OPPS,17.82,100,,,fee schedule,Pays 100% Medicare OPPS,23.17,130,,,fee schedule,Pays 130% Medicare OPPS,27,120.37,,,fee schedule,120.37% of custom fee schedule,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.18,102,,,fee schedule,Pays 102% Medicare OPPS,337.5,90,,,percent of total billed charges,90% of total billed charges,28.08,125.18,,,fee schedule,125.18% of custom fee schedule,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,17.82,100,,,fee schedule,Pays 100% Medicare OPPS,16.04,90,,,fee schedule,Pays 90% Medicare OPPS,217.5,58,,,percent of total billed charges,58% of total billed charges,27,120.37,,,fee schedule,120.37% of custom fee schedule,17.82,100,,,fee schedule,Pays 100% Medicare OPPS,23.17,130,,,fee schedule,Pays 130% Medicare OPPS,318.75,85,,,percent of total billed charges,85% of total billed charges,17.82,100,,,fee schedule,Pays 100% Medicare OPPS,16.04,337.5,
3RD LAMICTAL LEVEL,3000183,CDM,301,RC,80299,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.01,102,,,fee schedule,Pays 102% Medicare OPPS,337.5,90,,,percent of total billed charges,90% of total billed charges,18.95,125.18,,,fee schedule,125.18% of custom fee schedule,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,90,,,fee schedule,Pays 90% Medicare OPPS,217.5,58,,,percent of total billed charges,58% of total billed charges,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,318.75,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,337.5,
Blood test to assist with diagnosis,3000227,CDM,312,RC,88312,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,57.33,130,,,fee schedule,Pays 130% Medicare OPPS,52.23,120.37,,,fee schedule,120.37% of custom fee schedule,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.53,102,,,fee schedule,Pays 102% Medicare OPPS,337.5,90,,,percent of total billed charges,90% of total billed charges,54.32,125.18,,,fee schedule,125.18% of custom fee schedule,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,40.17,90,,,fee schedule,Pays 90% Medicare OPPS,217.5,58,,,percent of total billed charges,58% of total billed charges,52.23,120.37,,,fee schedule,120.37% of custom fee schedule,44.1,100,,,fee schedule,Pays 100% Medicare OPPS,57.33,130,,,fee schedule,Pays 130% Medicare OPPS,318.75,85,,,percent of total billed charges,85% of total billed charges,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,40.17,337.5,
TRAZODONE LEVEL,3000310,CDM,301,RC,80338,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,337.5,90,,,percent of total billed charges,90% of total billed charges,131.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,217.5,58,,,percent of total billed charges,58% of total billed charges,76.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,318.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,76.39,337.5,
3RD LIGHT CHAINS-UA IEP,3000327,CDM,302,RC,86334,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,22.34,100,,,fee schedule,Pays 100% Medicare OPPS,22.34,100,,,fee schedule,Pays 100% Medicare OPPS,22.34,100,,,fee schedule,Pays 100% Medicare OPPS,29.04,130,,,fee schedule,Pays 130% Medicare OPPS,33.81,120.37,,,fee schedule,120.37% of custom fee schedule,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.78,102,,,fee schedule,Pays 102% Medicare OPPS,337.5,90,,,percent of total billed charges,90% of total billed charges,35.16,125.18,,,fee schedule,125.18% of custom fee schedule,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,22.34,100,,,fee schedule,Pays 100% Medicare OPPS,20.1,90,,,fee schedule,Pays 90% Medicare OPPS,217.5,58,,,percent of total billed charges,58% of total billed charges,33.81,120.37,,,fee schedule,120.37% of custom fee schedule,22.34,100,,,fee schedule,Pays 100% Medicare OPPS,29.04,130,,,fee schedule,Pays 130% Medicare OPPS,318.75,85,,,percent of total billed charges,85% of total billed charges,22.34,100,,,fee schedule,Pays 100% Medicare OPPS,20.1,337.5,
NORTRIPTYLINE LEVEL,3080182,CDM,301,RC,80335,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,27.1,120.37,,,fee schedule,120.37% of custom fee schedule,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,337.5,90,,,percent of total billed charges,90% of total billed charges,28.18,125.18,,,fee schedule,125.18% of custom fee schedule,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,217.5,58,,,percent of total billed charges,58% of total billed charges,27.1,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,318.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,27.1,337.5,
MYSOLINE LEVEL,3080188,CDM,301,RC,80188,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,16.59,100,,,fee schedule,Pays 100% Medicare OPPS,16.59,100,,,fee schedule,Pays 100% Medicare OPPS,16.59,100,,,fee schedule,Pays 100% Medicare OPPS,21.56,130,,,fee schedule,Pays 130% Medicare OPPS,25.11,120.37,,,fee schedule,120.37% of custom fee schedule,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.92,102,,,fee schedule,Pays 102% Medicare OPPS,337.5,90,,,percent of total billed charges,90% of total billed charges,26.11,125.18,,,fee schedule,125.18% of custom fee schedule,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,16.59,100,,,fee schedule,Pays 100% Medicare OPPS,14.93,90,,,fee schedule,Pays 90% Medicare OPPS,217.5,58,,,percent of total billed charges,58% of total billed charges,25.11,120.37,,,fee schedule,120.37% of custom fee schedule,16.59,100,,,fee schedule,Pays 100% Medicare OPPS,21.56,130,,,fee schedule,Pays 130% Medicare OPPS,318.75,85,,,percent of total billed charges,85% of total billed charges,16.59,100,,,fee schedule,Pays 100% Medicare OPPS,14.93,337.5,
CORTISOL FREE URINE 24 HR,3082530,CDM,301,RC,82530,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,16.71,100,,,fee schedule,Pays 100% Medicare OPPS,16.71,100,,,fee schedule,Pays 100% Medicare OPPS,16.71,100,,,fee schedule,Pays 100% Medicare OPPS,21.72,130,,,fee schedule,Pays 130% Medicare OPPS,25.3,120.37,,,fee schedule,120.37% of custom fee schedule,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.04,102,,,fee schedule,Pays 102% Medicare OPPS,337.5,90,,,percent of total billed charges,90% of total billed charges,26.31,125.18,,,fee schedule,125.18% of custom fee schedule,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,16.71,100,,,fee schedule,Pays 100% Medicare OPPS,15.03,90,,,fee schedule,Pays 90% Medicare OPPS,217.5,58,,,percent of total billed charges,58% of total billed charges,25.3,120.37,,,fee schedule,120.37% of custom fee schedule,16.71,100,,,fee schedule,Pays 100% Medicare OPPS,21.72,130,,,fee schedule,Pays 130% Medicare OPPS,318.75,85,,,percent of total billed charges,85% of total billed charges,16.71,100,,,fee schedule,Pays 100% Medicare OPPS,15.03,337.5,
ETHYLENE GLYCOL,3082693,CDM,301,RC,82693,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,14.9,100,,,fee schedule,Pays 100% Medicare OPPS,14.9,100,,,fee schedule,Pays 100% Medicare OPPS,14.9,100,,,fee schedule,Pays 100% Medicare OPPS,19.37,130,,,fee schedule,Pays 130% Medicare OPPS,22.56,120.37,,,fee schedule,120.37% of custom fee schedule,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.19,102,,,fee schedule,Pays 102% Medicare OPPS,337.5,90,,,percent of total billed charges,90% of total billed charges,23.46,125.18,,,fee schedule,125.18% of custom fee schedule,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,14.9,100,,,fee schedule,Pays 100% Medicare OPPS,13.41,90,,,fee schedule,Pays 90% Medicare OPPS,217.5,58,,,percent of total billed charges,58% of total billed charges,22.56,120.37,,,fee schedule,120.37% of custom fee schedule,14.9,100,,,fee schedule,Pays 100% Medicare OPPS,19.37,130,,,fee schedule,Pays 130% Medicare OPPS,318.75,85,,,percent of total billed charges,85% of total billed charges,14.9,100,,,fee schedule,Pays 100% Medicare OPPS,13.41,337.5,
Test of hormone in the blood,3083001,CDM,301,RC,83001,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,18.57,100,,,fee schedule,Pays 100% Medicare OPPS,18.57,100,,,fee schedule,Pays 100% Medicare OPPS,18.57,100,,,fee schedule,Pays 100% Medicare OPPS,24.15,130,,,fee schedule,Pays 130% Medicare OPPS,28.13,120.37,,,fee schedule,120.37% of custom fee schedule,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.95,102,,,fee schedule,Pays 102% Medicare OPPS,337.5,90,,,percent of total billed charges,90% of total billed charges,29.25,125.18,,,fee schedule,125.18% of custom fee schedule,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,18.57,100,,,fee schedule,Pays 100% Medicare OPPS,16.72,90,,,fee schedule,Pays 90% Medicare OPPS,217.5,58,,,percent of total billed charges,58% of total billed charges,28.13,120.37,,,fee schedule,120.37% of custom fee schedule,18.57,100,,,fee schedule,Pays 100% Medicare OPPS,24.15,130,,,fee schedule,Pays 130% Medicare OPPS,318.75,85,,,percent of total billed charges,85% of total billed charges,18.57,100,,,fee schedule,Pays 100% Medicare OPPS,16.72,337.5,
"HYDROXYPROGESTERONE,17-AL",3083498,CDM,301,RC,83498,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,27.17,100,,,fee schedule,Pays 100% Medicare OPPS,27.17,100,,,fee schedule,Pays 100% Medicare OPPS,27.17,100,,,fee schedule,Pays 100% Medicare OPPS,35.32,130,,,fee schedule,Pays 130% Medicare OPPS,41.12,120.37,,,fee schedule,120.37% of custom fee schedule,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,27.71,102,,,fee schedule,Pays 102% Medicare OPPS,337.5,90,,,percent of total billed charges,90% of total billed charges,42.76,125.18,,,fee schedule,125.18% of custom fee schedule,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,27.17,100,,,fee schedule,Pays 100% Medicare OPPS,24.45,90,,,fee schedule,Pays 90% Medicare OPPS,217.5,58,,,percent of total billed charges,58% of total billed charges,41.12,120.37,,,fee schedule,120.37% of custom fee schedule,27.17,100,,,fee schedule,Pays 100% Medicare OPPS,35.32,130,,,fee schedule,Pays 130% Medicare OPPS,318.75,85,,,percent of total billed charges,85% of total billed charges,27.17,100,,,fee schedule,Pays 100% Medicare OPPS,24.45,337.5,
3RD CHROMOGRANIN-A,3083519,CDM,301,RC,86316,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,27.05,130,,,fee schedule,Pays 130% Medicare OPPS,31.49,120.37,,,fee schedule,120.37% of custom fee schedule,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,21.22,102,,,fee schedule,Pays 102% Medicare OPPS,337.5,90,,,percent of total billed charges,90% of total billed charges,32.75,125.18,,,fee schedule,125.18% of custom fee schedule,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,18.72,90,,,fee schedule,Pays 90% Medicare OPPS,217.5,58,,,percent of total billed charges,58% of total billed charges,31.49,120.37,,,fee schedule,120.37% of custom fee schedule,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,27.05,130,,,fee schedule,Pays 130% Medicare OPPS,318.75,85,,,percent of total billed charges,85% of total billed charges,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,18.72,337.5,
3RD LIGHT CHAINS-SERUM IEP,3083883,CDM,302,RC,83883,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,13.6,100,,,fee schedule,Pays 100% Medicare OPPS,13.6,100,,,fee schedule,Pays 100% Medicare OPPS,13.6,100,,,fee schedule,Pays 100% Medicare OPPS,17.68,130,,,fee schedule,Pays 130% Medicare OPPS,20.58,120.37,,,fee schedule,120.37% of custom fee schedule,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.87,102,,,fee schedule,Pays 102% Medicare OPPS,337.5,90,,,percent of total billed charges,90% of total billed charges,21.41,125.18,,,fee schedule,125.18% of custom fee schedule,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,13.6,100,,,fee schedule,Pays 100% Medicare OPPS,12.24,90,,,fee schedule,Pays 90% Medicare OPPS,217.5,58,,,percent of total billed charges,58% of total billed charges,20.58,120.37,,,fee schedule,120.37% of custom fee schedule,13.6,100,,,fee schedule,Pays 100% Medicare OPPS,17.68,130,,,fee schedule,Pays 130% Medicare OPPS,318.75,85,,,percent of total billed charges,85% of total billed charges,13.6,100,,,fee schedule,Pays 100% Medicare OPPS,12.24,337.5,
OSMOLALITY STOOL,3084999,CDM,301,RC,84999,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,337.5,90,,,percent of total billed charges,90% of total billed charges,131.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,217.5,58,,,percent of total billed charges,58% of total billed charges,76.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,318.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,76.39,337.5,
ANTITHROMBIN III ACTIVITY,3085300,CDM,305,RC,85300,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,11.85,100,,,fee schedule,Pays 100% Medicare OPPS,11.85,100,,,fee schedule,Pays 100% Medicare OPPS,11.85,100,,,fee schedule,Pays 100% Medicare OPPS,15.4,130,,,fee schedule,Pays 130% Medicare OPPS,17.94,120.37,,,fee schedule,120.37% of custom fee schedule,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.08,102,,,fee schedule,Pays 102% Medicare OPPS,337.5,90,,,percent of total billed charges,90% of total billed charges,18.65,125.18,,,fee schedule,125.18% of custom fee schedule,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,11.85,100,,,fee schedule,Pays 100% Medicare OPPS,10.66,90,,,fee schedule,Pays 90% Medicare OPPS,217.5,58,,,percent of total billed charges,58% of total billed charges,17.94,120.37,,,fee schedule,120.37% of custom fee schedule,11.85,100,,,fee schedule,Pays 100% Medicare OPPS,15.4,130,,,fee schedule,Pays 130% Medicare OPPS,318.75,85,,,percent of total billed charges,85% of total billed charges,11.85,100,,,fee schedule,Pays 100% Medicare OPPS,10.66,337.5,
IMMUNOFIXATION SERUM,3086334,CDM,302,RC,84155,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,3.67,100,,,fee schedule,Pays 100% Medicare OPPS,3.67,100,,,fee schedule,Pays 100% Medicare OPPS,3.67,100,,,fee schedule,Pays 100% Medicare OPPS,4.77,130,,,fee schedule,Pays 130% Medicare OPPS,5.55,120.37,,,fee schedule,120.37% of custom fee schedule,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3.74,102,,,fee schedule,Pays 102% Medicare OPPS,337.5,90,,,percent of total billed charges,90% of total billed charges,5.77,125.18,,,fee schedule,125.18% of custom fee schedule,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,3.67,100,,,fee schedule,Pays 100% Medicare OPPS,3.3,90,,,fee schedule,Pays 90% Medicare OPPS,217.5,58,,,percent of total billed charges,58% of total billed charges,5.55,120.37,,,fee schedule,120.37% of custom fee schedule,3.67,100,,,fee schedule,Pays 100% Medicare OPPS,4.77,130,,,fee schedule,Pays 130% Medicare OPPS,318.75,85,,,percent of total billed charges,85% of total billed charges,3.67,100,,,fee schedule,Pays 100% Medicare OPPS,3.3,337.5,
3RD ISLET CELL IgG AUTOAB,3086341,CDM,302,RC,86341,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,23.57,100,,,fee schedule,Pays 100% Medicare OPPS,23.57,100,,,fee schedule,Pays 100% Medicare OPPS,23.57,100,,,fee schedule,Pays 100% Medicare OPPS,30.64,130,,,fee schedule,Pays 130% Medicare OPPS,29.96,120.37,,,fee schedule,120.37% of custom fee schedule,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,24.04,102,,,fee schedule,Pays 102% Medicare OPPS,337.5,90,,,percent of total billed charges,90% of total billed charges,31.16,125.18,,,fee schedule,125.18% of custom fee schedule,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,23.57,100,,,fee schedule,Pays 100% Medicare OPPS,21.21,90,,,fee schedule,Pays 90% Medicare OPPS,217.5,58,,,percent of total billed charges,58% of total billed charges,29.96,120.37,,,fee schedule,120.37% of custom fee schedule,23.57,100,,,fee schedule,Pays 100% Medicare OPPS,30.64,130,,,fee schedule,Pays 130% Medicare OPPS,318.75,85,,,percent of total billed charges,85% of total billed charges,23.57,100,,,fee schedule,Pays 100% Medicare OPPS,21.21,337.5,
RITUXAN LEVEL,3086356,CDM,301,RC,86356,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,26.78,100,,,fee schedule,Pays 100% Medicare OPPS,26.78,100,,,fee schedule,Pays 100% Medicare OPPS,26.78,100,,,fee schedule,Pays 100% Medicare OPPS,34.81,130,,,fee schedule,Pays 130% Medicare OPPS,39.52,120.37,,,fee schedule,120.37% of custom fee schedule,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,27.31,102,,,fee schedule,Pays 102% Medicare OPPS,337.5,90,,,percent of total billed charges,90% of total billed charges,41.1,125.18,,,fee schedule,125.18% of custom fee schedule,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,26.78,100,,,fee schedule,Pays 100% Medicare OPPS,24.1,90,,,fee schedule,Pays 90% Medicare OPPS,217.5,58,,,percent of total billed charges,58% of total billed charges,39.52,120.37,,,fee schedule,120.37% of custom fee schedule,26.78,100,,,fee schedule,Pays 100% Medicare OPPS,34.81,130,,,fee schedule,Pays 130% Medicare OPPS,318.75,85,,,percent of total billed charges,85% of total billed charges,26.78,100,,,fee schedule,Pays 100% Medicare OPPS,24.1,337.5,
.DONATH-LANDSTEINER Ab,3086941,CDM,300,RC,86941,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,12.11,100,,,fee schedule,Pays 100% Medicare OPPS,12.11,100,,,fee schedule,Pays 100% Medicare OPPS,12.11,100,,,fee schedule,Pays 100% Medicare OPPS,15.74,130,,,fee schedule,Pays 130% Medicare OPPS,18.33,120.37,,,fee schedule,120.37% of custom fee schedule,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.35,102,,,fee schedule,Pays 102% Medicare OPPS,337.5,90,,,percent of total billed charges,90% of total billed charges,19.06,125.18,,,fee schedule,125.18% of custom fee schedule,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,12.11,100,,,fee schedule,Pays 100% Medicare OPPS,10.89,90,,,fee schedule,Pays 90% Medicare OPPS,217.5,58,,,percent of total billed charges,58% of total billed charges,18.33,120.37,,,fee schedule,120.37% of custom fee schedule,12.11,100,,,fee schedule,Pays 100% Medicare OPPS,15.74,130,,,fee schedule,Pays 130% Medicare OPPS,318.75,85,,,percent of total billed charges,85% of total billed charges,12.11,100,,,fee schedule,Pays 100% Medicare OPPS,10.89,337.5,
Test that detects Chlamydia,3087491,CDM,300,RC,87491,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,,,fee schedule,Pays 130% Medicare OPPS,29.7,120.37,,,fee schedule,120.37% of custom fee schedule,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,35.79,102,,,fee schedule,Pays 102% Medicare OPPS,337.5,90,,,percent of total billed charges,90% of total billed charges,30.88,125.18,,,fee schedule,125.18% of custom fee schedule,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,31.58,90,,,fee schedule,Pays 90% Medicare OPPS,217.5,58,,,percent of total billed charges,58% of total billed charges,29.7,120.37,,,fee schedule,120.37% of custom fee schedule,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,,,fee schedule,Pays 130% Medicare OPPS,318.75,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,29.7,337.5,
Blood test for an STD,3087591,CDM,300,RC,87591,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,,,fee schedule,Pays 130% Medicare OPPS,25.78,120.37,,,fee schedule,120.37% of custom fee schedule,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,35.79,102,,,fee schedule,Pays 102% Medicare OPPS,337.5,90,,,percent of total billed charges,90% of total billed charges,26.81,125.18,,,fee schedule,125.18% of custom fee schedule,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,31.58,90,,,fee schedule,Pays 90% Medicare OPPS,217.5,58,,,percent of total billed charges,58% of total billed charges,25.78,120.37,,,fee schedule,120.37% of custom fee schedule,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,,,fee schedule,Pays 130% Medicare OPPS,318.75,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,25.78,337.5,
CD 19/CD 3,3088184,CDM,300,RC,88184,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,370.6,130,,,fee schedule,Pays 130% Medicare OPPS,55.49,120.37,,,fee schedule,120.37% of custom fee schedule,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,266.86,102,,,fee schedule,Pays 102% Medicare OPPS,337.5,90,,,percent of total billed charges,90% of total billed charges,57.71,125.18,,,fee schedule,125.18% of custom fee schedule,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,235.46,90,,,fee schedule,Pays 90% Medicare OPPS,217.5,58,,,percent of total billed charges,58% of total billed charges,55.49,120.37,,,fee schedule,120.37% of custom fee schedule,285.08,100,,,fee schedule,Pays 100% Medicare OPPS,370.6,130,,,fee schedule,Pays 130% Medicare OPPS,318.75,85,,,percent of total billed charges,85% of total billed charges,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,55.49,370.6,
XR ABD/KUB,4074000,CDM,320,RC,74018,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,76.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,337.5,90,,,percent of total billed charges,90% of total billed charges,131.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,217.5,58,,,percent of total billed charges,58% of total billed charges,76.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,318.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,337.5,
XR COCCYX OR SACRUM,4074430,CDM,320,RC,72220,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,76.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,337.5,90,,,percent of total billed charges,90% of total billed charges,131.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,217.5,58,,,percent of total billed charges,58% of total billed charges,76.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,318.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,337.5,
XR BONE AGE,4076020,CDM,320,RC,77072,HCPCS,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,76.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,337.5,90,,,percent of total billed charges,90% of total billed charges,131.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,217.5,58,,,percent of total billed charges,58% of total billed charges,76.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,318.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,76.39,337.5,
THORACENTESIS TRAY,7905363,CDM,270,RC,,,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,337.5,90,,,percent of total billed charges,90% of total billed charges,131.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,217.5,58,,,percent of total billed charges,58% of total billed charges,76.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,318.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,76.39,337.5,
CATH KIT CENTRAL VENOUS AK15703,7905498,CDM,270,RC,,,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,337.5,90,,,percent of total billed charges,90% of total billed charges,131.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,217.5,58,,,percent of total billed charges,58% of total billed charges,76.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,318.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,76.39,337.5,
INTUBATION SET RETROGRADE,7905883,CDM,270,RC,,,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,337.5,90,,,percent of total billed charges,90% of total billed charges,131.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,217.5,58,,,percent of total billed charges,58% of total billed charges,76.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,318.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,76.39,337.5,
LINEAR CUTTER PROXIMATE 55MM TLC55,7950225,CDM,272,RC,,,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,337.5,90,,,percent of total billed charges,90% of total billed charges,131.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,217.5,58,,,percent of total billed charges,58% of total billed charges,76.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,318.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,76.39,337.5,
MARKER BREAST TISSUE ULTRACLIP 862017D,7950244,CDM,272,RC,,,Outpatient,,,375,300,,318.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,76.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,211.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,337.5,90,,,percent of total billed charges,90% of total billed charges,131.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,257.63,68.7,,,percent of total billed charges,68.7% of total billed charges,300,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,217.5,58,,,percent of total billed charges,58% of total billed charges,76.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,318.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,76.39,337.5,
SURGICEL NUKNIT 3 X 4,7905534,CDM,272,RC,,,Outpatient,,,380,304,,323,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,77.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,214.7,56.5,,,percent of total billed charges,56.5 percent of total billed charges,214.7,56.5,,,percent of total billed charges,56.5 percent of total billed charges,214.7,56.5,,,percent of total billed charges,56.5 percent of total billed charges,214.7,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,342,90,,,percent of total billed charges,90% of total billed charges,133,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,261.06,68.7,,,percent of total billed charges,68.7% of total billed charges,304,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,220.4,58,,,percent of total billed charges,58% of total billed charges,77.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,323,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,77.41,342,
SURGICEL 4 X 8 1952,7905099,CDM,272,RC,,,Outpatient,,,385,308,,327.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,78.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,217.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,217.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,217.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,217.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,346.5,90,,,percent of total billed charges,90% of total billed charges,134.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,264.5,68.7,,,percent of total billed charges,68.7% of total billed charges,308,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,223.3,58,,,percent of total billed charges,58% of total billed charges,78.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,327.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,78.42,346.5,
CONTINUOUS INHALATION TX 1ST HR,550005,CDM,410,RC,94644,HCPCS,Outpatient,,,390,312,,331.5,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,79.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,220.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,220.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,220.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,220.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,351,90,,,percent of total billed charges,90% of total billed charges,136.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,267.93,68.7,,,percent of total billed charges,68.7% of total billed charges,312,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,226.2,58,,,percent of total billed charges,58% of total billed charges,79.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,331.5,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,79.44,351,
BICILLIN-LA (PEN G BENZ) INJ 1.2MU,2601011,CDM,636,RC,J0561,HCPCS,Both,,,390,312,,331.5,85,,,percent of total billed charges,85% of total billed charges,16.73,100,,,fee schedule,Pays 100% Medicare OPPS,16.73,100,,,fee schedule,Pays 100% Medicare OPPS,16.73,100,,,fee schedule,Pays 100% Medicare OPPS,26.2,130,,,fee schedule,Pays 130% Medicare OPPS,20.14,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.05,102,,,fee schedule,Pays 102% Medicare OPPS,351,90,,,percent of total billed charges,90% of total billed charges,20.94,125.18,,,fee schedule,125.18% of custom fee schedule,267.93,68.7,,,percent of total billed charges,68.7% of total billed charges,312,80,,,percent of total billed charges,80 percent of total billed charges,16.73,100,,,fee schedule,Pays 100% Medicare OPPS,15.05,90,,,fee schedule,Pays 90% Medicare OPPS,226.2,58,,,percent of total billed charges,58% of total billed charges,20.14,120.37,,,fee schedule,120.37% of custom fee schedule,20.16,100,,,fee schedule,Pays 100% Medicare OPPS,26.2,130,,,fee schedule,Pays 130% Medicare OPPS,331.5,85,,,percent of total billed charges,85% of total billed charges,16.73,100,,,fee schedule,Pays 100% Medicare OPPS,15.05,351,
"THROMBIN TOPICAL 5,000 UNITS",2605013,CDM,637,RC,,,Outpatient,,,390,312,,331.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,79.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,220.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,220.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,220.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,220.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,351,90,,,percent of total billed charges,90% of total billed charges,136.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,267.93,68.7,,,percent of total billed charges,68.7% of total billed charges,312,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,226.2,58,,,percent of total billed charges,58% of total billed charges,79.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,331.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,79.44,351,
BRIDION (SUGAMMADEX) INJ 200MG,2610130,CDM,636,RC,,,Both,,,390,312,,331.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,79.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,351,90,,,percent of total billed charges,90% of total billed charges,136.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,267.93,68.7,,,percent of total billed charges,68.7% of total billed charges,312,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,226.2,58,,,percent of total billed charges,58% of total billed charges,79.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,331.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,79.44,351,
PEG KIT CORFLO 305020,7905848,CDM,270,RC,,,Outpatient,,,390,312,,331.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,79.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,220.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,220.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,220.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,220.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,351,90,,,percent of total billed charges,90% of total billed charges,136.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,267.93,68.7,,,percent of total billed charges,68.7% of total billed charges,312,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,226.2,58,,,percent of total billed charges,58% of total billed charges,79.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,331.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,79.44,351,
OBSERVATION 1ST HOUR,400001,CDM,762,RC,99219,HCPCS,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,335.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,80.46,355.5,
Outpatient visit of established patient not requiring a physician,1000006,CDM,761,RC,99211,HCPCS,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,335.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,80.46,355.5,
ISOLATION SUPPLIES,1000011,CDM,270,RC,,,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,335.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,80.46,355.5,
NASOGASTRIC TUBE PLACEMEN,1043752,CDM,762,RC,43752,HCPCS,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,243.8,100,,,fee schedule,Pays 100% Medicare OPPS,243.8,100,,,fee schedule,Pays 100% Medicare OPPS,243.8,100,,,fee schedule,Pays 100% Medicare OPPS,431.73,130,,,fee schedule,Pays 130% Medicare OPPS,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,248.67,102,,,fee schedule,Pays 102% Medicare OPPS,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,243.8,100,,,fee schedule,Pays 100% Medicare OPPS,219.42,90,,,fee schedule,Pays 90% Medicare OPPS,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,332.1,100,,,fee schedule,Pays 100% Medicare OPPS,431.73,130,,,fee schedule,Pays 130% Medicare OPPS,335.75,85,,,percent of total billed charges,85% of total billed charges,243.8,100,,,fee schedule,Pays 100% Medicare OPPS,80.46,431.73,
OUTPATIENT PROCEDURE/TREATMENT,1500006,CDM,761,RC,G0463,HCPCS,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,106.73,100,,,fee schedule,Pays 100% Medicare OPPS,106.73,100,,,fee schedule,Pays 100% Medicare OPPS,106.73,100,,,fee schedule,Pays 100% Medicare OPPS,138.19,130,,,fee schedule,Pays 130% Medicare OPPS,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,108.86,102,,,fee schedule,Pays 102% Medicare OPPS,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,106.73,100,,,fee schedule,Pays 100% Medicare OPPS,96.06,90,,,fee schedule,Pays 90% Medicare OPPS,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,106.3,100,,,fee schedule,Pays 100% Medicare OPPS,138.19,130,,,fee schedule,Pays 130% Medicare OPPS,335.75,85,,,percent of total billed charges,85% of total billed charges,106.73,100,,,fee schedule,Pays 100% Medicare OPPS,80.46,355.5,
DRILL 2.0,1570350,CDM,278,RC,A4649,HCPCS,Both,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,335.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,80.46,355.5,
FB REMOVAL EAR,2000011,CDM,450,RC,,,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,335.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,80.46,355.5,
FX CARPOMETACARPAL CLOSED W/MANIPULATIO,2026645,CDM,450,RC,,,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,335.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,80.46,355.5,
"FX PHALANGEAL, PROXIMAL CLOSED",2026725,CDM,450,RC,,,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,335.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,80.46,355.5,
"FX PHALANGEAL, DISTAL CLOSED",2026755,CDM,450,RC,,,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,335.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,80.46,355.5,
FX CALCANEAL CLOSED,2028400,CDM,450,RC,28400,HCPCS,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,188.85,102,,,fee schedule,Pays 102% Medicare OPPS,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,166.63,90,,,fee schedule,Pays 90% Medicare OPPS,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,182.08,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,335.75,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,80.46,355.5,
FX TOE CLOSED,2028490,CDM,450,RC,,,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,335.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,80.46,355.5,
FX TOE CLOSED,2028510,CDM,450,RC,,,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,335.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,80.46,355.5,
DISLOCATION INTERPHALANGEAL JOINT CLOSED,2028665,CDM,450,RC,,,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,335.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,80.46,355.5,
CAST SHORT ARM QK C,2029075,CDM,450,RC,,,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,335.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,80.46,355.5,
SPLINT APP ARM LONG,2029105,CDM,450,RC,,,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,335.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,80.46,355.5,
SPLINT APPLICATION ARM SHORT,2029125,CDM,450,RC,29125,HCPCS,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,335.75,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,80.46,355.5,
STRAPPING OF SHOULDER,2029240,CDM,450,RC,,,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,335.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,80.46,355.5,
SPLINT APP LEG,2029505,CDM,450,RC,29505,HCPCS,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,166.66,130,,,fee schedule,Pays 130% Medicare OPPS,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,129.44,102,,,fee schedule,Pays 102% Medicare OPPS,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,114.22,90,,,fee schedule,Pays 90% Medicare OPPS,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,128.19,100,,,fee schedule,Pays 100% Medicare OPPS,166.66,130,,,fee schedule,Pays 130% Medicare OPPS,335.75,85,,,percent of total billed charges,85% of total billed charges,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,80.46,355.5,
SPLINT APP LOWER LEG,2029515,CDM,450,RC,29515,HCPCS,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,166.66,130,,,fee schedule,Pays 130% Medicare OPPS,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,129.44,102,,,fee schedule,Pays 102% Medicare OPPS,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,114.22,90,,,fee schedule,Pays 90% Medicare OPPS,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,128.19,100,,,fee schedule,Pays 100% Medicare OPPS,166.66,130,,,fee schedule,Pays 130% Medicare OPPS,335.75,85,,,percent of total billed charges,85% of total billed charges,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,80.46,355.5,
CASTING STRAPPING PROCEDU,2029799,CDM,450,RC,29799,HCPCS,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,166.66,130,,,fee schedule,Pays 130% Medicare OPPS,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,129.44,102,,,fee schedule,Pays 102% Medicare OPPS,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,114.22,90,,,fee schedule,Pays 90% Medicare OPPS,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,128.19,100,,,fee schedule,Pays 100% Medicare OPPS,166.66,130,,,fee schedule,Pays 130% Medicare OPPS,335.75,85,,,percent of total billed charges,85% of total billed charges,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,80.46,355.5,
NASOGASTRIC TUBE PLACEMEN,2043752,CDM,450,RC,43752,HCPCS,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,243.8,100,,,fee schedule,Pays 100% Medicare OPPS,243.8,100,,,fee schedule,Pays 100% Medicare OPPS,243.8,100,,,fee schedule,Pays 100% Medicare OPPS,431.73,130,,,fee schedule,Pays 130% Medicare OPPS,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,248.67,102,,,fee schedule,Pays 102% Medicare OPPS,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,243.8,100,,,fee schedule,Pays 100% Medicare OPPS,219.42,90,,,fee schedule,Pays 90% Medicare OPPS,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,332.1,100,,,fee schedule,Pays 100% Medicare OPPS,431.73,130,,,fee schedule,Pays 130% Medicare OPPS,335.75,85,,,percent of total billed charges,85% of total billed charges,243.8,100,,,fee schedule,Pays 100% Medicare OPPS,80.46,431.73,
Outpatient visit of established patient not requiring a physician,2099211,CDM,761,RC,99211,HCPCS,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,335.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,80.46,355.5,
TOBRADEX (TOBRAMYCIN/DEX) OPHT OINT,2603080,CDM,637,RC,,,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,335.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,80.46,355.5,
3RD ZONISAMIDE (ZONEGRAN) LEVEL,3000339,CDM,301,RC,80299,HCPCS,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.01,102,,,fee schedule,Pays 102% Medicare OPPS,355.5,90,,,percent of total billed charges,90% of total billed charges,18.95,125.18,,,fee schedule,125.18% of custom fee schedule,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,90,,,fee schedule,Pays 90% Medicare OPPS,229.1,58,,,percent of total billed charges,58% of total billed charges,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,335.75,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,355.5,
"Blood test, lipids (cholesterol and triglycerides)",3080061,CDM,301,RC,80061,HCPCS,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,13.39,100,,,fee schedule,Pays 100% Medicare OPPS,13.39,100,,,fee schedule,Pays 100% Medicare OPPS,13.39,100,,,fee schedule,Pays 100% Medicare OPPS,17.4,130,,,fee schedule,Pays 130% Medicare OPPS,20.28,120.37,,,fee schedule,120.37% of custom fee schedule,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.65,102,,,fee schedule,Pays 102% Medicare OPPS,355.5,90,,,percent of total billed charges,90% of total billed charges,21.09,125.18,,,fee schedule,125.18% of custom fee schedule,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,13.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,90,,,fee schedule,Pays 90% Medicare OPPS,229.1,58,,,percent of total billed charges,58% of total billed charges,20.28,120.37,,,fee schedule,120.37% of custom fee schedule,13.39,100,,,fee schedule,Pays 100% Medicare OPPS,17.4,130,,,fee schedule,Pays 130% Medicare OPPS,335.75,85,,,percent of total billed charges,85% of total billed charges,13.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,355.5,
3RD TSH RECEPTOR ANTIBODY,3084445,CDM,300,RC,84445,HCPCS,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,50.86,100,,,fee schedule,Pays 100% Medicare OPPS,50.86,100,,,fee schedule,Pays 100% Medicare OPPS,50.86,100,,,fee schedule,Pays 100% Medicare OPPS,66.11,130,,,fee schedule,Pays 130% Medicare OPPS,12.82,120.37,,,fee schedule,120.37% of custom fee schedule,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,51.87,102,,,fee schedule,Pays 102% Medicare OPPS,355.5,90,,,percent of total billed charges,90% of total billed charges,13.33,125.18,,,fee schedule,125.18% of custom fee schedule,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,50.86,100,,,fee schedule,Pays 100% Medicare OPPS,45.77,90,,,fee schedule,Pays 90% Medicare OPPS,229.1,58,,,percent of total billed charges,58% of total billed charges,12.82,120.37,,,fee schedule,120.37% of custom fee schedule,50.86,100,,,fee schedule,Pays 100% Medicare OPPS,66.11,130,,,fee schedule,Pays 130% Medicare OPPS,335.75,85,,,percent of total billed charges,85% of total billed charges,50.86,100,,,fee schedule,Pays 100% Medicare OPPS,12.82,355.5,
VITAMIN A LEVEL,3084590,CDM,301,RC,84590,HCPCS,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,11.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.61,100,,,fee schedule,Pays 100% Medicare OPPS,11.61,100,,,fee schedule,Pays 100% Medicare OPPS,15.09,130,,,fee schedule,Pays 130% Medicare OPPS,17.55,120.37,,,fee schedule,120.37% of custom fee schedule,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.84,102,,,fee schedule,Pays 102% Medicare OPPS,355.5,90,,,percent of total billed charges,90% of total billed charges,18.25,125.18,,,fee schedule,125.18% of custom fee schedule,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,11.61,100,,,fee schedule,Pays 100% Medicare OPPS,10.44,90,,,fee schedule,Pays 90% Medicare OPPS,229.1,58,,,percent of total billed charges,58% of total billed charges,17.55,120.37,,,fee schedule,120.37% of custom fee schedule,11.61,100,,,fee schedule,Pays 100% Medicare OPPS,15.09,130,,,fee schedule,Pays 130% Medicare OPPS,335.75,85,,,percent of total billed charges,85% of total billed charges,11.61,100,,,fee schedule,Pays 100% Medicare OPPS,10.44,355.5,
ANTI FACTOR XA (LOVENOX),3085520,CDM,300,RC,85520,HCPCS,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,13.09,100,,,fee schedule,Pays 100% Medicare OPPS,13.09,100,,,fee schedule,Pays 100% Medicare OPPS,13.09,100,,,fee schedule,Pays 100% Medicare OPPS,17.01,130,,,fee schedule,Pays 130% Medicare OPPS,19.81,120.37,,,fee schedule,120.37% of custom fee schedule,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.35,102,,,fee schedule,Pays 102% Medicare OPPS,355.5,90,,,percent of total billed charges,90% of total billed charges,20.6,125.18,,,fee schedule,125.18% of custom fee schedule,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,13.09,100,,,fee schedule,Pays 100% Medicare OPPS,11.78,90,,,fee schedule,Pays 90% Medicare OPPS,229.1,58,,,percent of total billed charges,58% of total billed charges,19.81,120.37,,,fee schedule,120.37% of custom fee schedule,13.09,100,,,fee schedule,Pays 100% Medicare OPPS,17.01,130,,,fee schedule,Pays 130% Medicare OPPS,335.75,85,,,percent of total billed charges,85% of total billed charges,13.09,100,,,fee schedule,Pays 100% Medicare OPPS,11.78,355.5,
XR INJECTION SHOULDER ARTHROGRAM,4023350,CDM,322,RC,23350,HCPCS,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,221.99,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,335.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,80.46,355.5,
XR RIBS UNILAT LEFT W/O PA CHEST 2 VIEW,4071100,CDM,320,RC,71100,HCPCS,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,221.99,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,335.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,355.5,
XR RIBS UNILAT RT W/O PA CHEST 2 VIEW,4081100,CDM,320,RC,71100,HCPCS,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,221.99,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,335.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,355.5,
PT UNNA BOOT APPLICATION (PER SESSION),5029580,CDM,420,RC,29580,HCPCS,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,166.66,130,,,fee schedule,Pays 130% Medicare OPPS,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,129.44,102,,,fee schedule,Pays 102% Medicare OPPS,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,114.22,90,,,fee schedule,Pays 90% Medicare OPPS,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,128.19,100,,,fee schedule,Pays 100% Medicare OPPS,166.66,130,,,fee schedule,Pays 130% Medicare OPPS,335.75,85,,,percent of total billed charges,85% of total billed charges,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,80.46,355.5,
PT MOD-EVALUATION (PER SESSION),5097001,CDM,424,RC,97001,HCPCS,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,335.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,80.46,355.5,
PT EVAL LOW COMPLEXITY,5097161,CDM,424,RC,97161,HCPCS,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,96.5,100,,,fee schedule,Pays 100% Medicare OPPS,96.5,100,,,fee schedule,Pays 100% Medicare OPPS,96.5,100,,,fee schedule,Pays 100% Medicare OPPS,124.74,130,,,fee schedule,Pays 130% Medicare OPPS,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.43,102,,,fee schedule,Pays 102% Medicare OPPS,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,96.5,100,,,fee schedule,Pays 100% Medicare OPPS,86.85,90,,,fee schedule,Pays 90% Medicare OPPS,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,95.95,100,,,fee schedule,Pays 100% Medicare OPPS,124.74,130,,,fee schedule,Pays 130% Medicare OPPS,335.75,85,,,percent of total billed charges,85% of total billed charges,96.5,100,,,fee schedule,Pays 100% Medicare OPPS,80.46,355.5,
PT EVAL MODERATE COMPLEXITY,5097162,CDM,424,RC,97162,HCPCS,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,96.5,100,,,fee schedule,Pays 100% Medicare OPPS,96.5,100,,,fee schedule,Pays 100% Medicare OPPS,96.5,100,,,fee schedule,Pays 100% Medicare OPPS,124.74,130,,,fee schedule,Pays 130% Medicare OPPS,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.43,102,,,fee schedule,Pays 102% Medicare OPPS,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,96.5,100,,,fee schedule,Pays 100% Medicare OPPS,86.85,90,,,fee schedule,Pays 90% Medicare OPPS,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,95.95,100,,,fee schedule,Pays 100% Medicare OPPS,124.74,130,,,fee schedule,Pays 130% Medicare OPPS,335.75,85,,,percent of total billed charges,85% of total billed charges,96.5,100,,,fee schedule,Pays 100% Medicare OPPS,80.46,355.5,
PT EVAL HIGH COMPLEXITY,5097163,CDM,424,RC,97163,HCPCS,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,96.5,100,,,fee schedule,Pays 100% Medicare OPPS,96.5,100,,,fee schedule,Pays 100% Medicare OPPS,96.5,100,,,fee schedule,Pays 100% Medicare OPPS,124.74,130,,,fee schedule,Pays 130% Medicare OPPS,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,98.43,102,,,fee schedule,Pays 102% Medicare OPPS,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,96.5,100,,,fee schedule,Pays 100% Medicare OPPS,86.85,90,,,fee schedule,Pays 90% Medicare OPPS,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,95.95,100,,,fee schedule,Pays 100% Medicare OPPS,124.74,130,,,fee schedule,Pays 130% Medicare OPPS,335.75,85,,,percent of total billed charges,85% of total billed charges,96.5,100,,,fee schedule,Pays 100% Medicare OPPS,80.46,355.5,
OT EVALUATION (PER SESSION),5197003,CDM,434,RC,97003,HCPCS,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,335.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,80.46,355.5,
Test to determine how well oxygen moves from the lungs to the blood stream,5500001,CDM,460,RC,94010,HCPCS,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,125.41,100,,,fee schedule,Pays 100% Medicare OPPS,125.41,100,,,fee schedule,Pays 100% Medicare OPPS,125.41,100,,,fee schedule,Pays 100% Medicare OPPS,166.29,130,,,fee schedule,Pays 130% Medicare OPPS,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,127.92,102,,,fee schedule,Pays 102% Medicare OPPS,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,125.41,100,,,fee schedule,Pays 100% Medicare OPPS,112.87,90,,,fee schedule,Pays 90% Medicare OPPS,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,127.91,100,,,fee schedule,Pays 100% Medicare OPPS,166.29,130,,,fee schedule,Pays 130% Medicare OPPS,335.75,85,,,percent of total billed charges,85% of total billed charges,125.41,100,,,fee schedule,Pays 100% Medicare OPPS,80.46,355.5,
Test to measure how well gases diffuse across lung surfaces,5594350,CDM,460,RC,94729,HCPCS,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,335.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,80.46,355.5,
NEEDLE SADOWSKY,7950115,CDM,270,RC,,,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,335.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,80.46,355.5,
TROCAR XCEL BLADELESS B11LT,7950266,CDM,270,RC,,,Outpatient,,,395,316,,335.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,223.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,355.5,90,,,percent of total billed charges,90% of total billed charges,138.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,271.37,68.7,,,percent of total billed charges,68.7% of total billed charges,316,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,229.1,58,,,percent of total billed charges,58% of total billed charges,80.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,335.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,80.46,355.5,
PT WORK HARDENING 1 2HR,5097545,CDM,420,RC,97545,HCPCS,Outpatient,,,400,320,,340,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,81.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,226,56.5,,,percent of total billed charges,56.5 percent of total billed charges,226,56.5,,,percent of total billed charges,56.5 percent of total billed charges,226,56.5,,,percent of total billed charges,56.5 percent of total billed charges,226,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,360,90,,,percent of total billed charges,90% of total billed charges,140,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,274.8,68.7,,,percent of total billed charges,68.7% of total billed charges,320,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,232,58,,,percent of total billed charges,58% of total billed charges,81.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,340,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,81.48,360,
SUB NEB TX,5500005,CDM,410,RC,94640,HCPCS,Outpatient,,,400,320,,340,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,81.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,226,56.5,,,percent of total billed charges,56.5 percent of total billed charges,226,56.5,,,percent of total billed charges,56.5 percent of total billed charges,226,56.5,,,percent of total billed charges,56.5 percent of total billed charges,226,56.5,,,percent of total billed charges,56.5 percent of total billed charges,172.23,102,,,fee schedule,Pays 102% Medicare OPPS,360,90,,,percent of total billed charges,90% of total billed charges,140,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,274.8,68.7,,,percent of total billed charges,68.7% of total billed charges,320,80,,,percent of total billed charges,80 percent of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,151.96,90,,,fee schedule,Pays 90% Medicare OPPS,232,58,,,percent of total billed charges,58% of total billed charges,81.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,168.43,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,340,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,81.48,360,
NASACORT AQ (TRIAMCINOLONE) NASAL SPRAY,2605054,CDM,637,RC,,,Outpatient,,,405,324,,344.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,82.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,228.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,228.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,228.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,228.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,364.5,90,,,percent of total billed charges,90% of total billed charges,141.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,278.24,68.7,,,percent of total billed charges,68.7% of total billed charges,324,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,234.9,58,,,percent of total billed charges,58% of total billed charges,82.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,344.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,82.5,364.5,
IN & OUT CATHETERIZATION,1051701,CDM,450,RC,51701,HCPCS,Outpatient,,,410,328,,348.5,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,83.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,369,90,,,percent of total billed charges,90% of total billed charges,143.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,281.67,68.7,,,percent of total billed charges,68.7% of total billed charges,328,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,237.8,58,,,percent of total billed charges,58% of total billed charges,83.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,348.5,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,83.52,369,
BURN DRESSING APPLICATION,2016020,CDM,450,RC,,,Outpatient,,,410,328,,348.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,83.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,369,90,,,percent of total billed charges,90% of total billed charges,143.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,281.67,68.7,,,percent of total billed charges,68.7% of total billed charges,328,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,237.8,58,,,percent of total billed charges,58% of total billed charges,83.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,348.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,83.52,369,
IN & OUT CATHETERIZATION,2051701,CDM,450,RC,51701,HCPCS,Outpatient,,,410,328,,348.5,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,83.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,369,90,,,percent of total billed charges,90% of total billed charges,143.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,281.67,68.7,,,percent of total billed charges,68.7% of total billed charges,328,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,237.8,58,,,percent of total billed charges,58% of total billed charges,83.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,348.5,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,83.52,369,
Blood test to identify bacteria that may be contributing to symptoms in the gastrointestinal tract,3000074,CDM,306,RC,87046,HCPCS,Outpatient,,,410,328,,348.5,85,,,percent of total billed charges,85% of total billed charges,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,12.27,130,,,fee schedule,Pays 130% Medicare OPPS,3.57,120.37,,,fee schedule,120.37% of custom fee schedule,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.62,102,,,fee schedule,Pays 102% Medicare OPPS,369,90,,,percent of total billed charges,90% of total billed charges,3.72,125.18,,,fee schedule,125.18% of custom fee schedule,281.67,68.7,,,percent of total billed charges,68.7% of total billed charges,328,80,,,percent of total billed charges,80 percent of total billed charges,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,8.49,90,,,fee schedule,Pays 90% Medicare OPPS,237.8,58,,,percent of total billed charges,58% of total billed charges,3.57,120.37,,,fee schedule,120.37% of custom fee schedule,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,12.27,130,,,fee schedule,Pays 130% Medicare OPPS,348.5,85,,,percent of total billed charges,85% of total billed charges,9.44,100,,,fee schedule,Pays 100% Medicare OPPS,3.57,369,
DESYREL LEVEL,3000084,CDM,301,RC,80338,HCPCS,Outpatient,,,410,328,,348.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,83.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,369,90,,,percent of total billed charges,90% of total billed charges,143.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,281.67,68.7,,,percent of total billed charges,68.7% of total billed charges,328,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,237.8,58,,,percent of total billed charges,58% of total billed charges,83.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,348.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,83.52,369,
"Blood test, thyroid stimulating hormone (TSH)",3000317,CDM,301,RC,84443,HCPCS,Outpatient,,,410,328,,348.5,85,,,percent of total billed charges,85% of total billed charges,16.8,100,,,fee schedule,Pays 100% Medicare OPPS,16.8,100,,,fee schedule,Pays 100% Medicare OPPS,16.8,100,,,fee schedule,Pays 100% Medicare OPPS,21.84,130,,,fee schedule,Pays 130% Medicare OPPS,25.42,120.37,,,fee schedule,120.37% of custom fee schedule,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.13,102,,,fee schedule,Pays 102% Medicare OPPS,369,90,,,percent of total billed charges,90% of total billed charges,26.44,125.18,,,fee schedule,125.18% of custom fee schedule,281.67,68.7,,,percent of total billed charges,68.7% of total billed charges,328,80,,,percent of total billed charges,80 percent of total billed charges,16.8,100,,,fee schedule,Pays 100% Medicare OPPS,15.12,90,,,fee schedule,Pays 90% Medicare OPPS,237.8,58,,,percent of total billed charges,58% of total billed charges,25.42,120.37,,,fee schedule,120.37% of custom fee schedule,16.8,100,,,fee schedule,Pays 100% Medicare OPPS,21.84,130,,,fee schedule,Pays 130% Medicare OPPS,348.5,85,,,percent of total billed charges,85% of total billed charges,16.8,100,,,fee schedule,Pays 100% Medicare OPPS,15.12,369,
Liver function blood test panel,3080076,CDM,301,RC,80076,HCPCS,Outpatient,,,410,328,,348.5,85,,,percent of total billed charges,85% of total billed charges,8.17,100,,,fee schedule,Pays 100% Medicare OPPS,8.17,100,,,fee schedule,Pays 100% Medicare OPPS,8.17,100,,,fee schedule,Pays 100% Medicare OPPS,10.62,130,,,fee schedule,Pays 130% Medicare OPPS,12.37,120.37,,,fee schedule,120.37% of custom fee schedule,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.33,102,,,fee schedule,Pays 102% Medicare OPPS,369,90,,,percent of total billed charges,90% of total billed charges,12.87,125.18,,,fee schedule,125.18% of custom fee schedule,281.67,68.7,,,percent of total billed charges,68.7% of total billed charges,328,80,,,percent of total billed charges,80 percent of total billed charges,8.17,100,,,fee schedule,Pays 100% Medicare OPPS,7.35,90,,,fee schedule,Pays 90% Medicare OPPS,237.8,58,,,percent of total billed charges,58% of total billed charges,12.37,120.37,,,fee schedule,120.37% of custom fee schedule,8.17,100,,,fee schedule,Pays 100% Medicare OPPS,10.62,130,,,fee schedule,Pays 130% Medicare OPPS,348.5,85,,,percent of total billed charges,85% of total billed charges,8.17,100,,,fee schedule,Pays 100% Medicare OPPS,7.35,369,
SALICYLATE (SERUM TEST),3080196,CDM,301,RC,80329,HCPCS,Outpatient,,,410,328,,348.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,30.63,120.37,,,fee schedule,120.37% of custom fee schedule,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,369,90,,,percent of total billed charges,90% of total billed charges,31.86,125.18,,,fee schedule,125.18% of custom fee schedule,281.67,68.7,,,percent of total billed charges,68.7% of total billed charges,328,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,237.8,58,,,percent of total billed charges,58% of total billed charges,30.63,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,348.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,30.63,369,
ACETAMINOPHEN (SERUM TEST),3082003,CDM,301,RC,80329,HCPCS,Outpatient,,,410,328,,348.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,30.63,120.37,,,fee schedule,120.37% of custom fee schedule,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,369,90,,,percent of total billed charges,90% of total billed charges,31.86,125.18,,,fee schedule,125.18% of custom fee schedule,281.67,68.7,,,percent of total billed charges,68.7% of total billed charges,328,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,237.8,58,,,percent of total billed charges,58% of total billed charges,30.63,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,348.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,30.63,369,
ALCOHOL (SERUM TEST),3082055,CDM,301,RC,80320,HCPCS,Outpatient,,,410,328,,348.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,16.36,120.37,,,fee schedule,120.37% of custom fee schedule,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,369,90,,,percent of total billed charges,90% of total billed charges,17.01,125.18,,,fee schedule,125.18% of custom fee schedule,281.67,68.7,,,percent of total billed charges,68.7% of total billed charges,328,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,237.8,58,,,percent of total billed charges,58% of total billed charges,16.36,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,348.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,16.36,369,
AMMONIA LEVEL,3082140,CDM,301,RC,82140,HCPCS,Outpatient,,,410,328,,348.5,85,,,percent of total billed charges,85% of total billed charges,14.57,100,,,fee schedule,Pays 100% Medicare OPPS,14.57,100,,,fee schedule,Pays 100% Medicare OPPS,14.57,100,,,fee schedule,Pays 100% Medicare OPPS,18.94,130,,,fee schedule,Pays 130% Medicare OPPS,14.97,120.37,,,fee schedule,120.37% of custom fee schedule,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.86,102,,,fee schedule,Pays 102% Medicare OPPS,369,90,,,percent of total billed charges,90% of total billed charges,15.57,125.18,,,fee schedule,125.18% of custom fee schedule,281.67,68.7,,,percent of total billed charges,68.7% of total billed charges,328,80,,,percent of total billed charges,80 percent of total billed charges,14.57,100,,,fee schedule,Pays 100% Medicare OPPS,13.11,90,,,fee schedule,Pays 90% Medicare OPPS,237.8,58,,,percent of total billed charges,58% of total billed charges,14.97,120.37,,,fee schedule,120.37% of custom fee schedule,14.57,100,,,fee schedule,Pays 100% Medicare OPPS,18.94,130,,,fee schedule,Pays 130% Medicare OPPS,348.5,85,,,percent of total billed charges,85% of total billed charges,14.57,100,,,fee schedule,Pays 100% Medicare OPPS,13.11,369,
PROLACTIN LEVEL,3084146,CDM,301,RC,84146,HCPCS,Outpatient,,,410,328,,348.5,85,,,percent of total billed charges,85% of total billed charges,19.38,100,,,fee schedule,Pays 100% Medicare OPPS,19.38,100,,,fee schedule,Pays 100% Medicare OPPS,19.38,100,,,fee schedule,Pays 100% Medicare OPPS,25.19,130,,,fee schedule,Pays 130% Medicare OPPS,29.33,120.37,,,fee schedule,120.37% of custom fee schedule,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.76,102,,,fee schedule,Pays 102% Medicare OPPS,369,90,,,percent of total billed charges,90% of total billed charges,30.51,125.18,,,fee schedule,125.18% of custom fee schedule,281.67,68.7,,,percent of total billed charges,68.7% of total billed charges,328,80,,,percent of total billed charges,80 percent of total billed charges,19.38,100,,,fee schedule,Pays 100% Medicare OPPS,17.44,90,,,fee schedule,Pays 90% Medicare OPPS,237.8,58,,,percent of total billed charges,58% of total billed charges,29.33,120.37,,,fee schedule,120.37% of custom fee schedule,19.38,100,,,fee schedule,Pays 100% Medicare OPPS,25.19,130,,,fee schedule,Pays 130% Medicare OPPS,348.5,85,,,percent of total billed charges,85% of total billed charges,19.38,100,,,fee schedule,Pays 100% Medicare OPPS,17.44,369,
RENIN LEVEL,3084244,CDM,301,RC,84244,HCPCS,Outpatient,,,410,328,,348.5,85,,,percent of total billed charges,85% of total billed charges,21.99,100,,,fee schedule,Pays 100% Medicare OPPS,21.99,100,,,fee schedule,Pays 100% Medicare OPPS,21.99,100,,,fee schedule,Pays 100% Medicare OPPS,28.58,130,,,fee schedule,Pays 130% Medicare OPPS,33.29,120.37,,,fee schedule,120.37% of custom fee schedule,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.42,102,,,fee schedule,Pays 102% Medicare OPPS,369,90,,,percent of total billed charges,90% of total billed charges,34.62,125.18,,,fee schedule,125.18% of custom fee schedule,281.67,68.7,,,percent of total billed charges,68.7% of total billed charges,328,80,,,percent of total billed charges,80 percent of total billed charges,21.99,100,,,fee schedule,Pays 100% Medicare OPPS,19.79,90,,,fee schedule,Pays 90% Medicare OPPS,237.8,58,,,percent of total billed charges,58% of total billed charges,33.29,120.37,,,fee schedule,120.37% of custom fee schedule,21.99,100,,,fee schedule,Pays 100% Medicare OPPS,28.58,130,,,fee schedule,Pays 130% Medicare OPPS,348.5,85,,,percent of total billed charges,85% of total billed charges,21.99,100,,,fee schedule,Pays 100% Medicare OPPS,19.79,369,
FACTOR V ACTIVITY,3085220,CDM,305,RC,85220,HCPCS,Outpatient,,,410,328,,348.5,85,,,percent of total billed charges,85% of total billed charges,17.64,100,,,fee schedule,Pays 100% Medicare OPPS,17.64,100,,,fee schedule,Pays 100% Medicare OPPS,17.64,100,,,fee schedule,Pays 100% Medicare OPPS,22.94,130,,,fee schedule,Pays 130% Medicare OPPS,26.71,120.37,,,fee schedule,120.37% of custom fee schedule,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18,102,,,fee schedule,Pays 102% Medicare OPPS,369,90,,,percent of total billed charges,90% of total billed charges,27.78,125.18,,,fee schedule,125.18% of custom fee schedule,281.67,68.7,,,percent of total billed charges,68.7% of total billed charges,328,80,,,percent of total billed charges,80 percent of total billed charges,17.64,100,,,fee schedule,Pays 100% Medicare OPPS,15.88,90,,,fee schedule,Pays 90% Medicare OPPS,237.8,58,,,percent of total billed charges,58% of total billed charges,26.71,120.37,,,fee schedule,120.37% of custom fee schedule,17.64,100,,,fee schedule,Pays 100% Medicare OPPS,22.94,130,,,fee schedule,Pays 130% Medicare OPPS,348.5,85,,,percent of total billed charges,85% of total billed charges,17.64,100,,,fee schedule,Pays 100% Medicare OPPS,15.88,369,
"2 views, front and back",4071035,CDM,324,RC,71046,HCPCS,Outpatient,,,410,328,,348.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,83.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,230.42,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,369,90,,,percent of total billed charges,90% of total billed charges,143.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,281.67,68.7,,,percent of total billed charges,68.7% of total billed charges,328,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.38,90,,,fee schedule,Pays 90% Medicare OPPS,237.8,58,,,percent of total billed charges,58% of total billed charges,83.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,348.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.38,369,
XR SACROILLIAC JOINTS 3 VIEW,4072202,CDM,320,RC,72202,HCPCS,Outpatient,,,410,328,,348.5,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,83.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,230.42,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,369,90,,,percent of total billed charges,90% of total billed charges,143.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,281.67,68.7,,,percent of total billed charges,68.7% of total billed charges,328,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,237.8,58,,,percent of total billed charges,58% of total billed charges,83.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,348.5,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,83.52,369,
Measure of lung function and gas exchange,5500003,CDM,460,RC,94727,HCPCS,Outpatient,,,410,328,,348.5,85,,,percent of total billed charges,85% of total billed charges,125.41,100,,,fee schedule,Pays 100% Medicare OPPS,125.41,100,,,fee schedule,Pays 100% Medicare OPPS,125.41,100,,,fee schedule,Pays 100% Medicare OPPS,166.29,130,,,fee schedule,Pays 130% Medicare OPPS,83.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,231.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,127.92,102,,,fee schedule,Pays 102% Medicare OPPS,369,90,,,percent of total billed charges,90% of total billed charges,143.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,281.67,68.7,,,percent of total billed charges,68.7% of total billed charges,328,80,,,percent of total billed charges,80 percent of total billed charges,125.41,100,,,fee schedule,Pays 100% Medicare OPPS,112.87,90,,,fee schedule,Pays 90% Medicare OPPS,237.8,58,,,percent of total billed charges,58% of total billed charges,83.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,127.91,100,,,fee schedule,Pays 100% Medicare OPPS,166.29,130,,,fee schedule,Pays 130% Medicare OPPS,348.5,85,,,percent of total billed charges,85% of total billed charges,125.41,100,,,fee schedule,Pays 100% Medicare OPPS,83.52,369,
POWERPICC CATHETER 5FR SL,7905968,CDM,278,RC,C1751,HCPCS,Both,,,410,328,,348.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,83.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,369,90,,,percent of total billed charges,90% of total billed charges,143.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,281.67,68.7,,,percent of total billed charges,68.7% of total billed charges,328,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,237.8,58,,,percent of total billed charges,58% of total billed charges,83.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,348.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,83.52,369,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",490765,CDM,760,RC,96365,HCPCS,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,187.43,102,,,fee schedule,Pays 102% Medicare OPPS,373.5,90,,,percent of total billed charges,90% of total billed charges,145.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,165.38,90,,,fee schedule,Pays 90% Medicare OPPS,240.7,58,,,percent of total billed charges,58% of total billed charges,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,181.69,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,352.75,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,84.54,373.5,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",1090765,CDM,760,RC,96365,HCPCS,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,187.43,102,,,fee schedule,Pays 102% Medicare OPPS,373.5,90,,,percent of total billed charges,90% of total billed charges,145.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,165.38,90,,,fee schedule,Pays 90% Medicare OPPS,240.7,58,,,percent of total billed charges,58% of total billed charges,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,181.69,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,352.75,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,84.54,373.5,
MU MONITOR/TELE,1093041,CDM,270,RC,,,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,373.5,90,,,percent of total billed charges,90% of total billed charges,145.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,240.7,58,,,percent of total billed charges,58% of total billed charges,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,352.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,84.54,373.5,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",1096365,CDM,760,RC,96365,HCPCS,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,187.43,102,,,fee schedule,Pays 102% Medicare OPPS,373.5,90,,,percent of total billed charges,90% of total billed charges,145.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,165.38,90,,,fee schedule,Pays 90% Medicare OPPS,240.7,58,,,percent of total billed charges,58% of total billed charges,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,181.69,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,352.75,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,84.54,373.5,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",1596365,CDM,760,RC,96365,HCPCS,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,187.43,102,,,fee schedule,Pays 102% Medicare OPPS,373.5,90,,,percent of total billed charges,90% of total billed charges,145.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,165.38,90,,,fee schedule,Pays 90% Medicare OPPS,240.7,58,,,percent of total billed charges,58% of total billed charges,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,181.69,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,352.75,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,84.54,373.5,
CARDIAC MONITOR ER,2000005,CDM,270,RC,,,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,103.75,100,,,fee schedule,Pays 100% Medicare OPPS,103.75,100,,,fee schedule,Pays 100% Medicare OPPS,103.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,373.5,90,,,percent of total billed charges,90% of total billed charges,145.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,373.5,90,,,fee schedule,Pays 90% Medicare OPPS,240.7,58,,,percent of total billed charges,58% of total billed charges,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,352.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,84.54,373.5,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",2090765,CDM,450,RC,96365,HCPCS,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,187.43,102,,,fee schedule,Pays 102% Medicare OPPS,373.5,90,,,percent of total billed charges,90% of total billed charges,145.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,165.38,90,,,fee schedule,Pays 90% Medicare OPPS,240.7,58,,,percent of total billed charges,58% of total billed charges,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,181.69,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,352.75,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,84.54,373.5,
....CARDIAC MONITOR - ER,2093041,CDM,270,RC,,,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,103.75,100,,,fee schedule,Pays 100% Medicare OPPS,103.75,100,,,fee schedule,Pays 100% Medicare OPPS,103.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,373.5,90,,,percent of total billed charges,90% of total billed charges,145.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,373.5,90,,,fee schedule,Pays 90% Medicare OPPS,240.7,58,,,percent of total billed charges,58% of total billed charges,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,352.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,84.54,373.5,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",2096365,CDM,450,RC,96365,HCPCS,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,187.43,102,,,fee schedule,Pays 102% Medicare OPPS,373.5,90,,,percent of total billed charges,90% of total billed charges,145.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,165.38,90,,,fee schedule,Pays 90% Medicare OPPS,240.7,58,,,percent of total billed charges,58% of total billed charges,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,181.69,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,352.75,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,84.54,373.5,
LEVAQUIN 750MG IV PREMIX,2605193,CDM,636,RC,J1956,HCPCS,Both,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,103.75,100,,,fee schedule,Pays 100% Medicare OPPS,103.75,100,,,fee schedule,Pays 100% Medicare OPPS,103.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,373.5,90,,,percent of total billed charges,90% of total billed charges,145.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,373.5,90,,,fee schedule,Pays 90% Medicare OPPS,240.7,58,,,percent of total billed charges,58% of total billed charges,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,352.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,84.54,373.5,
CATECHOLAMINES PLASMA,3000039,CDM,301,RC,82384,HCPCS,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,25.25,100,,,fee schedule,Pays 100% Medicare OPPS,25.25,100,,,fee schedule,Pays 100% Medicare OPPS,25.25,100,,,fee schedule,Pays 100% Medicare OPPS,32.82,130,,,fee schedule,Pays 130% Medicare OPPS,38.22,120.37,,,fee schedule,120.37% of custom fee schedule,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.75,102,,,fee schedule,Pays 102% Medicare OPPS,373.5,90,,,percent of total billed charges,90% of total billed charges,39.74,125.18,,,fee schedule,125.18% of custom fee schedule,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,25.25,100,,,fee schedule,Pays 100% Medicare OPPS,22.72,90,,,fee schedule,Pays 90% Medicare OPPS,240.7,58,,,percent of total billed charges,58% of total billed charges,38.22,120.37,,,fee schedule,120.37% of custom fee schedule,25.25,100,,,fee schedule,Pays 100% Medicare OPPS,32.82,130,,,fee schedule,Pays 130% Medicare OPPS,352.75,85,,,percent of total billed charges,85% of total billed charges,25.25,100,,,fee schedule,Pays 100% Medicare OPPS,22.72,373.5,
LIPOMED (NMR),3000188,CDM,301,RC,83704,HCPCS,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,34.19,100,,,fee schedule,Pays 100% Medicare OPPS,34.19,100,,,fee schedule,Pays 100% Medicare OPPS,34.19,100,,,fee schedule,Pays 100% Medicare OPPS,44.44,130,,,fee schedule,Pays 130% Medicare OPPS,47.75,120.37,,,fee schedule,120.37% of custom fee schedule,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,34.87,102,,,fee schedule,Pays 102% Medicare OPPS,373.5,90,,,percent of total billed charges,90% of total billed charges,49.66,125.18,,,fee schedule,125.18% of custom fee schedule,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,34.19,100,,,fee schedule,Pays 100% Medicare OPPS,30.77,90,,,fee schedule,Pays 90% Medicare OPPS,240.7,58,,,percent of total billed charges,58% of total billed charges,47.75,120.37,,,fee schedule,120.37% of custom fee schedule,34.19,100,,,fee schedule,Pays 100% Medicare OPPS,44.44,130,,,fee schedule,Pays 130% Medicare OPPS,352.75,85,,,percent of total billed charges,85% of total billed charges,34.19,100,,,fee schedule,Pays 100% Medicare OPPS,30.77,373.5,
C- PEPTIDE,3000229,CDM,301,RC,84681,HCPCS,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,27.05,130,,,fee schedule,Pays 130% Medicare OPPS,24.05,120.37,,,fee schedule,120.37% of custom fee schedule,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,21.22,102,,,fee schedule,Pays 102% Medicare OPPS,373.5,90,,,percent of total billed charges,90% of total billed charges,25.01,125.18,,,fee schedule,125.18% of custom fee schedule,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,18.72,90,,,fee schedule,Pays 90% Medicare OPPS,240.7,58,,,percent of total billed charges,58% of total billed charges,24.05,120.37,,,fee schedule,120.37% of custom fee schedule,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,27.05,130,,,fee schedule,Pays 130% Medicare OPPS,352.75,85,,,percent of total billed charges,85% of total billed charges,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,18.72,373.5,
TRILEPTAL,3000311,CDM,301,RC,80299,HCPCS,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.01,102,,,fee schedule,Pays 102% Medicare OPPS,373.5,90,,,percent of total billed charges,90% of total billed charges,18.95,125.18,,,fee schedule,125.18% of custom fee schedule,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,90,,,fee schedule,Pays 90% Medicare OPPS,240.7,58,,,percent of total billed charges,58% of total billed charges,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,352.75,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,373.5,
Prostate cancer screening; prostate specific antigen test (psa),3000343,CDM,300,RC,G0103,HCPCS,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,19.3,100,,,fee schedule,Pays 100% Medicare OPPS,19.3,100,,,fee schedule,Pays 100% Medicare OPPS,19.3,100,,,fee schedule,Pays 100% Medicare OPPS,25.1,130,,,fee schedule,Pays 130% Medicare OPPS,30.94,120.37,,,fee schedule,120.37% of custom fee schedule,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.69,102,,,fee schedule,Pays 102% Medicare OPPS,373.5,90,,,percent of total billed charges,90% of total billed charges,32.17,125.18,,,fee schedule,125.18% of custom fee schedule,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,19.3,100,,,fee schedule,Pays 100% Medicare OPPS,17.37,90,,,fee schedule,Pays 90% Medicare OPPS,240.7,58,,,percent of total billed charges,58% of total billed charges,30.94,120.37,,,fee schedule,120.37% of custom fee schedule,19.3,100,,,fee schedule,Pays 100% Medicare OPPS,25.1,130,,,fee schedule,Pays 130% Medicare OPPS,352.75,85,,,percent of total billed charges,85% of total billed charges,19.3,100,,,fee schedule,Pays 100% Medicare OPPS,17.37,373.5,
CATECHOLAMINE UA 24 HR,3000646,CDM,301,RC,82384,HCPCS,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,25.25,100,,,fee schedule,Pays 100% Medicare OPPS,25.25,100,,,fee schedule,Pays 100% Medicare OPPS,25.25,100,,,fee schedule,Pays 100% Medicare OPPS,32.82,130,,,fee schedule,Pays 130% Medicare OPPS,38.22,120.37,,,fee schedule,120.37% of custom fee schedule,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.75,102,,,fee schedule,Pays 102% Medicare OPPS,373.5,90,,,percent of total billed charges,90% of total billed charges,39.74,125.18,,,fee schedule,125.18% of custom fee schedule,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,25.25,100,,,fee schedule,Pays 100% Medicare OPPS,22.72,90,,,fee schedule,Pays 90% Medicare OPPS,240.7,58,,,percent of total billed charges,58% of total billed charges,38.22,120.37,,,fee schedule,120.37% of custom fee schedule,25.25,100,,,fee schedule,Pays 100% Medicare OPPS,32.82,130,,,fee schedule,Pays 130% Medicare OPPS,352.75,85,,,percent of total billed charges,85% of total billed charges,25.25,100,,,fee schedule,Pays 100% Medicare OPPS,22.72,373.5,
Test is used to measure the amount of the drug in the blood to determine whether the concentration has reached a therapeutic level and is below the to,3080197,CDM,301,RC,80197,HCPCS,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,13.73,100,,,fee schedule,Pays 100% Medicare OPPS,13.73,100,,,fee schedule,Pays 100% Medicare OPPS,13.73,100,,,fee schedule,Pays 100% Medicare OPPS,17.84,130,,,fee schedule,Pays 130% Medicare OPPS,20.76,120.37,,,fee schedule,120.37% of custom fee schedule,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14,102,,,fee schedule,Pays 102% Medicare OPPS,373.5,90,,,percent of total billed charges,90% of total billed charges,21.59,125.18,,,fee schedule,125.18% of custom fee schedule,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,13.73,100,,,fee schedule,Pays 100% Medicare OPPS,12.35,90,,,fee schedule,Pays 90% Medicare OPPS,240.7,58,,,percent of total billed charges,58% of total billed charges,20.76,120.37,,,fee schedule,120.37% of custom fee schedule,13.73,100,,,fee schedule,Pays 100% Medicare OPPS,17.84,130,,,fee schedule,Pays 130% Medicare OPPS,352.75,85,,,percent of total billed charges,85% of total billed charges,13.73,100,,,fee schedule,Pays 100% Medicare OPPS,12.35,373.5,
3RD TOPIRAMATE (TOPAMAX) LEVEL,3080201,CDM,301,RC,80201,HCPCS,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,11.92,100,,,fee schedule,Pays 100% Medicare OPPS,11.92,100,,,fee schedule,Pays 100% Medicare OPPS,11.92,100,,,fee schedule,Pays 100% Medicare OPPS,15.49,130,,,fee schedule,Pays 130% Medicare OPPS,18.04,120.37,,,fee schedule,120.37% of custom fee schedule,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.15,102,,,fee schedule,Pays 102% Medicare OPPS,373.5,90,,,percent of total billed charges,90% of total billed charges,18.76,125.18,,,fee schedule,125.18% of custom fee schedule,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,11.92,100,,,fee schedule,Pays 100% Medicare OPPS,10.72,90,,,fee schedule,Pays 90% Medicare OPPS,240.7,58,,,percent of total billed charges,58% of total billed charges,18.04,120.37,,,fee schedule,120.37% of custom fee schedule,11.92,100,,,fee schedule,Pays 100% Medicare OPPS,15.49,130,,,fee schedule,Pays 130% Medicare OPPS,352.75,85,,,percent of total billed charges,85% of total billed charges,11.92,100,,,fee schedule,Pays 100% Medicare OPPS,10.72,373.5,
CALCITONIN,3082308,CDM,301,RC,82308,HCPCS,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,26.79,100,,,fee schedule,Pays 100% Medicare OPPS,26.79,100,,,fee schedule,Pays 100% Medicare OPPS,26.79,100,,,fee schedule,Pays 100% Medicare OPPS,34.82,130,,,fee schedule,Pays 130% Medicare OPPS,40.53,120.37,,,fee schedule,120.37% of custom fee schedule,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,27.32,102,,,fee schedule,Pays 102% Medicare OPPS,373.5,90,,,percent of total billed charges,90% of total billed charges,42.15,125.18,,,fee schedule,125.18% of custom fee schedule,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,26.79,100,,,fee schedule,Pays 100% Medicare OPPS,24.11,90,,,fee schedule,Pays 90% Medicare OPPS,240.7,58,,,percent of total billed charges,58% of total billed charges,40.53,120.37,,,fee schedule,120.37% of custom fee schedule,26.79,100,,,fee schedule,Pays 100% Medicare OPPS,34.82,130,,,fee schedule,Pays 130% Medicare OPPS,352.75,85,,,percent of total billed charges,85% of total billed charges,26.79,100,,,fee schedule,Pays 100% Medicare OPPS,24.11,373.5,
"CARNITINE,SERUM",3082379,CDM,300,RC,82379,HCPCS,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,16.87,100,,,fee schedule,Pays 100% Medicare OPPS,16.87,100,,,fee schedule,Pays 100% Medicare OPPS,16.87,100,,,fee schedule,Pays 100% Medicare OPPS,21.93,130,,,fee schedule,Pays 130% Medicare OPPS,25.53,120.37,,,fee schedule,120.37% of custom fee schedule,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.2,102,,,fee schedule,Pays 102% Medicare OPPS,373.5,90,,,percent of total billed charges,90% of total billed charges,26.55,125.18,,,fee schedule,125.18% of custom fee schedule,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,16.87,100,,,fee schedule,Pays 100% Medicare OPPS,15.18,90,,,fee schedule,Pays 90% Medicare OPPS,240.7,58,,,percent of total billed charges,58% of total billed charges,25.53,120.37,,,fee schedule,120.37% of custom fee schedule,16.87,100,,,fee schedule,Pays 100% Medicare OPPS,21.93,130,,,fee schedule,Pays 130% Medicare OPPS,352.75,85,,,percent of total billed charges,85% of total billed charges,16.87,100,,,fee schedule,Pays 100% Medicare OPPS,15.18,373.5,
CATECHOLAMINE UA RANDOM,3082384,CDM,301,RC,82384,HCPCS,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,25.25,100,,,fee schedule,Pays 100% Medicare OPPS,25.25,100,,,fee schedule,Pays 100% Medicare OPPS,25.25,100,,,fee schedule,Pays 100% Medicare OPPS,32.82,130,,,fee schedule,Pays 130% Medicare OPPS,38.22,120.37,,,fee schedule,120.37% of custom fee schedule,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.75,102,,,fee schedule,Pays 102% Medicare OPPS,373.5,90,,,percent of total billed charges,90% of total billed charges,39.74,125.18,,,fee schedule,125.18% of custom fee schedule,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,25.25,100,,,fee schedule,Pays 100% Medicare OPPS,22.72,90,,,fee schedule,Pays 90% Medicare OPPS,240.7,58,,,percent of total billed charges,58% of total billed charges,38.22,120.37,,,fee schedule,120.37% of custom fee schedule,25.25,100,,,fee schedule,Pays 100% Medicare OPPS,32.82,130,,,fee schedule,Pays 130% Medicare OPPS,352.75,85,,,percent of total billed charges,85% of total billed charges,25.25,100,,,fee schedule,Pays 100% Medicare OPPS,22.72,373.5,
ESTRONE LEVEL,3082679,CDM,301,RC,82679,HCPCS,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,24.95,100,,,fee schedule,Pays 100% Medicare OPPS,24.95,100,,,fee schedule,Pays 100% Medicare OPPS,24.95,100,,,fee schedule,Pays 100% Medicare OPPS,32.43,130,,,fee schedule,Pays 130% Medicare OPPS,37.78,120.37,,,fee schedule,120.37% of custom fee schedule,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,25.44,102,,,fee schedule,Pays 102% Medicare OPPS,373.5,90,,,percent of total billed charges,90% of total billed charges,39.29,125.18,,,fee schedule,125.18% of custom fee schedule,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,24.95,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,90,,,fee schedule,Pays 90% Medicare OPPS,240.7,58,,,percent of total billed charges,58% of total billed charges,37.78,120.37,,,fee schedule,120.37% of custom fee schedule,24.95,100,,,fee schedule,Pays 100% Medicare OPPS,32.43,130,,,fee schedule,Pays 130% Medicare OPPS,352.75,85,,,percent of total billed charges,85% of total billed charges,24.95,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,373.5,
OLIGOCLONAL BANDS IgG (CSF),3083916,CDM,301,RC,83916,HCPCS,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,27.39,100,,,fee schedule,Pays 100% Medicare OPPS,27.39,100,,,fee schedule,Pays 100% Medicare OPPS,27.39,100,,,fee schedule,Pays 100% Medicare OPPS,35.6,130,,,fee schedule,Pays 130% Medicare OPPS,30.43,120.37,,,fee schedule,120.37% of custom fee schedule,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,27.93,102,,,fee schedule,Pays 102% Medicare OPPS,373.5,90,,,percent of total billed charges,90% of total billed charges,31.65,125.18,,,fee schedule,125.18% of custom fee schedule,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,27.39,100,,,fee schedule,Pays 100% Medicare OPPS,24.65,90,,,fee schedule,Pays 90% Medicare OPPS,240.7,58,,,percent of total billed charges,58% of total billed charges,30.43,120.37,,,fee schedule,120.37% of custom fee schedule,27.39,100,,,fee schedule,Pays 100% Medicare OPPS,35.6,130,,,fee schedule,Pays 130% Medicare OPPS,352.75,85,,,percent of total billed charges,85% of total billed charges,27.39,100,,,fee schedule,Pays 100% Medicare OPPS,24.65,373.5,
PROCALCITONIN,3084145,CDM,301,RC,84145,HCPCS,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,27.22,100,,,fee schedule,Pays 100% Medicare OPPS,27.22,100,,,fee schedule,Pays 100% Medicare OPPS,27.22,100,,,fee schedule,Pays 100% Medicare OPPS,35.38,130,,,fee schedule,Pays 130% Medicare OPPS,28.96,120.37,,,fee schedule,120.37% of custom fee schedule,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,27.76,102,,,fee schedule,Pays 102% Medicare OPPS,373.5,90,,,percent of total billed charges,90% of total billed charges,30.12,125.18,,,fee schedule,125.18% of custom fee schedule,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,27.22,100,,,fee schedule,Pays 100% Medicare OPPS,24.49,90,,,fee schedule,Pays 90% Medicare OPPS,240.7,58,,,percent of total billed charges,58% of total billed charges,28.96,120.37,,,fee schedule,120.37% of custom fee schedule,27.22,100,,,fee schedule,Pays 100% Medicare OPPS,35.38,130,,,fee schedule,Pays 130% Medicare OPPS,352.75,85,,,percent of total billed charges,85% of total billed charges,27.22,100,,,fee schedule,Pays 100% Medicare OPPS,24.49,373.5,
PSA (prostate specific antigen),3084153,CDM,301,RC,84153,HCPCS,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,23.9,130,,,fee schedule,Pays 130% Medicare OPPS,27.84,120.37,,,fee schedule,120.37% of custom fee schedule,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.75,102,,,fee schedule,Pays 102% Medicare OPPS,373.5,90,,,percent of total billed charges,90% of total billed charges,28.95,125.18,,,fee schedule,125.18% of custom fee schedule,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.55,90,,,fee schedule,Pays 90% Medicare OPPS,240.7,58,,,percent of total billed charges,58% of total billed charges,27.84,120.37,,,fee schedule,120.37% of custom fee schedule,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,23.9,130,,,fee schedule,Pays 130% Medicare OPPS,352.75,85,,,percent of total billed charges,85% of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.55,373.5,
C PEPTIDE,3084681,CDM,301,RC,84681,HCPCS,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,27.05,130,,,fee schedule,Pays 130% Medicare OPPS,24.05,120.37,,,fee schedule,120.37% of custom fee schedule,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,21.22,102,,,fee schedule,Pays 102% Medicare OPPS,373.5,90,,,percent of total billed charges,90% of total billed charges,25.01,125.18,,,fee schedule,125.18% of custom fee schedule,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,18.72,90,,,fee schedule,Pays 90% Medicare OPPS,240.7,58,,,percent of total billed charges,58% of total billed charges,24.05,120.37,,,fee schedule,120.37% of custom fee schedule,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,27.05,130,,,fee schedule,Pays 130% Medicare OPPS,352.75,85,,,percent of total billed charges,85% of total billed charges,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,18.72,373.5,
3RD INSULIN ANTIBODIES,3086337,CDM,302,RC,86337,HCPCS,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,21.41,100,,,fee schedule,Pays 100% Medicare OPPS,21.41,100,,,fee schedule,Pays 100% Medicare OPPS,21.41,100,,,fee schedule,Pays 100% Medicare OPPS,27.83,130,,,fee schedule,Pays 130% Medicare OPPS,32.42,120.37,,,fee schedule,120.37% of custom fee schedule,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,21.83,102,,,fee schedule,Pays 102% Medicare OPPS,373.5,90,,,percent of total billed charges,90% of total billed charges,33.71,125.18,,,fee schedule,125.18% of custom fee schedule,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,21.41,100,,,fee schedule,Pays 100% Medicare OPPS,19.26,90,,,fee schedule,Pays 90% Medicare OPPS,240.7,58,,,percent of total billed charges,58% of total billed charges,32.42,120.37,,,fee schedule,120.37% of custom fee schedule,21.41,100,,,fee schedule,Pays 100% Medicare OPPS,27.83,130,,,fee schedule,Pays 130% Medicare OPPS,352.75,85,,,percent of total billed charges,85% of total billed charges,21.41,100,,,fee schedule,Pays 100% Medicare OPPS,19.26,373.5,
BIOPSY TRAY,4000802,CDM,270,RC,,,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,373.5,90,,,percent of total billed charges,90% of total billed charges,145.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,240.7,58,,,percent of total billed charges,58% of total billed charges,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,352.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,84.54,373.5,
XR INJECTION SINUS TRACT OR DRAIN,4049424,CDM,320,RC,49424,HCPCS,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,233.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,373.5,90,,,percent of total billed charges,90% of total billed charges,145.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,240.7,58,,,percent of total billed charges,58% of total billed charges,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,352.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,84.54,373.5,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",4090765,CDM,760,RC,96365,HCPCS,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,187.43,102,,,fee schedule,Pays 102% Medicare OPPS,373.5,90,,,percent of total billed charges,90% of total billed charges,145.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,165.38,90,,,fee schedule,Pays 90% Medicare OPPS,240.7,58,,,percent of total billed charges,58% of total billed charges,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,181.69,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,352.75,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,84.54,373.5,
LUMBO-SACRAL SUPPORT,7905267,CDM,270,RC,,,Outpatient,,,415,332,,352.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,234.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,373.5,90,,,percent of total billed charges,90% of total billed charges,145.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,285.11,68.7,,,percent of total billed charges,68.7% of total billed charges,332,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,240.7,58,,,percent of total billed charges,58% of total billed charges,84.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,352.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,84.54,373.5,
C REP TRUNK EA ADTL 5CM,2013102,CDM,450,RC,13102,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,357,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,85.55,378,
STRAPPING ANKLE & OR FOOT,2029540,CDM,450,RC,,,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,357,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,85.55,378,
REM FB CONEAL W SLIT LAMP,2065222,CDM,450,RC,65222,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,85.55,378,
CEFTIN (CEFUROXIME 50ML) SUSP 125MG/5ML,2605022,CDM,637,RC,,,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,357,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,85.55,378,
Obstetric blood test panel,3000104,CDM,301,RC,80055,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,47.81,100,,,fee schedule,Pays 100% Medicare OPPS,47.81,100,,,fee schedule,Pays 100% Medicare OPPS,47.81,100,,,fee schedule,Pays 100% Medicare OPPS,62.15,130,,,fee schedule,Pays 130% Medicare OPPS,33.8,120.37,,,fee schedule,120.37% of custom fee schedule,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.76,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,35.15,125.18,,,fee schedule,125.18% of custom fee schedule,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,47.81,100,,,fee schedule,Pays 100% Medicare OPPS,43.02,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,33.8,120.37,,,fee schedule,120.37% of custom fee schedule,47.81,100,,,fee schedule,Pays 100% Medicare OPPS,62.15,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,47.81,100,,,fee schedule,Pays 100% Medicare OPPS,33.8,378,
I-STAT BMP,3080047,CDM,301,RC,80047,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,13.73,100,,,fee schedule,Pays 100% Medicare OPPS,13.73,100,,,fee schedule,Pays 100% Medicare OPPS,13.73,100,,,fee schedule,Pays 100% Medicare OPPS,17.84,130,,,fee schedule,Pays 130% Medicare OPPS,33.05,120.37,,,fee schedule,120.37% of custom fee schedule,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,34.37,125.18,,,fee schedule,125.18% of custom fee schedule,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,13.73,100,,,fee schedule,Pays 100% Medicare OPPS,12.35,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,33.05,120.37,,,fee schedule,120.37% of custom fee schedule,13.73,100,,,fee schedule,Pays 100% Medicare OPPS,17.84,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,13.73,100,,,fee schedule,Pays 100% Medicare OPPS,12.35,378,
Basic metabolic panel,3080048,CDM,301,RC,80048,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,8.46,100,,,fee schedule,Pays 100% Medicare OPPS,8.46,100,,,fee schedule,Pays 100% Medicare OPPS,8.46,100,,,fee schedule,Pays 100% Medicare OPPS,10.99,130,,,fee schedule,Pays 130% Medicare OPPS,12.82,120.37,,,fee schedule,120.37% of custom fee schedule,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.62,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,13.33,125.18,,,fee schedule,125.18% of custom fee schedule,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,8.46,100,,,fee schedule,Pays 100% Medicare OPPS,7.61,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,12.82,120.37,,,fee schedule,120.37% of custom fee schedule,8.46,100,,,fee schedule,Pays 100% Medicare OPPS,10.99,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,8.46,100,,,fee schedule,Pays 100% Medicare OPPS,7.61,378,
AMIODARONE,3080299,CDM,301,RC,80299,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.01,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,18.95,125.18,,,fee schedule,125.18% of custom fee schedule,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,378,
L/S RATIO,3083661,CDM,301,RC,83661,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,21.99,100,,,fee schedule,Pays 100% Medicare OPPS,21.99,100,,,fee schedule,Pays 100% Medicare OPPS,21.99,100,,,fee schedule,Pays 100% Medicare OPPS,28.58,130,,,fee schedule,Pays 130% Medicare OPPS,33.27,120.37,,,fee schedule,120.37% of custom fee schedule,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.42,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,34.6,125.18,,,fee schedule,125.18% of custom fee schedule,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,21.99,100,,,fee schedule,Pays 100% Medicare OPPS,19.79,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,33.27,120.37,,,fee schedule,120.37% of custom fee schedule,21.99,100,,,fee schedule,Pays 100% Medicare OPPS,28.58,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,21.99,100,,,fee schedule,Pays 100% Medicare OPPS,19.79,378,
MEPROBAMATE SERUM LEVEL,3083805,CDM,301,RC,80369,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,26.69,120.37,,,fee schedule,120.37% of custom fee schedule,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,378,90,,,percent of total billed charges,90% of total billed charges,27.75,125.18,,,fee schedule,125.18% of custom fee schedule,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,243.6,58,,,percent of total billed charges,58% of total billed charges,26.69,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,357,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,26.69,378,
Blood test used to diagnose heart failure,3083880,CDM,301,RC,83880,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,39.26,100,,,fee schedule,Pays 100% Medicare OPPS,39.26,100,,,fee schedule,Pays 100% Medicare OPPS,39.26,100,,,fee schedule,Pays 100% Medicare OPPS,51.03,130,,,fee schedule,Pays 130% Medicare OPPS,51.39,120.37,,,fee schedule,120.37% of custom fee schedule,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,40.04,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,53.44,125.18,,,fee schedule,125.18% of custom fee schedule,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,39.26,100,,,fee schedule,Pays 100% Medicare OPPS,35.33,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,51.39,120.37,,,fee schedule,120.37% of custom fee schedule,39.26,100,,,fee schedule,Pays 100% Medicare OPPS,51.03,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,39.26,100,,,fee schedule,Pays 100% Medicare OPPS,35.33,378,
....PBG (,3084106,CDM,301,RC,84106,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,7.56,130,,,fee schedule,Pays 130% Medicare OPPS,6.49,120.37,,,fee schedule,120.37% of custom fee schedule,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,5.93,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,6.75,125.18,,,fee schedule,125.18% of custom fee schedule,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,5.23,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,6.49,120.37,,,fee schedule,120.37% of custom fee schedule,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,7.56,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,5.82,100,,,fee schedule,Pays 100% Medicare OPPS,5.23,378,
IGF-1,3084305,CDM,301,RC,84305,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,21.26,100,,,fee schedule,Pays 100% Medicare OPPS,21.26,100,,,fee schedule,Pays 100% Medicare OPPS,21.26,100,,,fee schedule,Pays 100% Medicare OPPS,27.63,130,,,fee schedule,Pays 130% Medicare OPPS,32.17,120.37,,,fee schedule,120.37% of custom fee schedule,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,21.68,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,33.46,125.18,,,fee schedule,125.18% of custom fee schedule,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,21.26,100,,,fee schedule,Pays 100% Medicare OPPS,19.13,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,32.17,120.37,,,fee schedule,120.37% of custom fee schedule,21.26,100,,,fee schedule,Pays 100% Medicare OPPS,27.63,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,21.26,100,,,fee schedule,Pays 100% Medicare OPPS,19.13,378,
ANCA,3086021,CDM,302,RC,86038,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,12.09,100,,,fee schedule,Pays 100% Medicare OPPS,12.09,100,,,fee schedule,Pays 100% Medicare OPPS,12.09,100,,,fee schedule,Pays 100% Medicare OPPS,15.71,130,,,fee schedule,Pays 130% Medicare OPPS,18.3,120.37,,,fee schedule,120.37% of custom fee schedule,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.33,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,19.03,125.18,,,fee schedule,125.18% of custom fee schedule,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,12.09,100,,,fee schedule,Pays 100% Medicare OPPS,10.88,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,18.3,120.37,,,fee schedule,120.37% of custom fee schedule,12.09,100,,,fee schedule,Pays 100% Medicare OPPS,15.71,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,12.09,100,,,fee schedule,Pays 100% Medicare OPPS,10.88,378,
HLA B-27 ANTIGEN,3086812,CDM,302,RC,86812,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,25.81,100,,,fee schedule,Pays 100% Medicare OPPS,25.81,100,,,fee schedule,Pays 100% Medicare OPPS,25.81,100,,,fee schedule,Pays 100% Medicare OPPS,33.55,130,,,fee schedule,Pays 130% Medicare OPPS,39.06,120.37,,,fee schedule,120.37% of custom fee schedule,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,26.32,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,40.62,125.18,,,fee schedule,125.18% of custom fee schedule,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,25.81,100,,,fee schedule,Pays 100% Medicare OPPS,23.22,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,39.06,120.37,,,fee schedule,120.37% of custom fee schedule,25.81,100,,,fee schedule,Pays 100% Medicare OPPS,33.55,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,25.81,100,,,fee schedule,Pays 100% Medicare OPPS,23.22,378,
BB PLATELET UNIT,3109019,CDM,390,RC,P9019,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,72.79,100,,,fee schedule,Pays 100% Medicare OPPS,72.79,100,,,fee schedule,Pays 100% Medicare OPPS,72.79,100,,,fee schedule,Pays 100% Medicare OPPS,100.39,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.23,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,72.79,100,,,fee schedule,Pays 100% Medicare OPPS,65.51,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,77.23,100,,,fee schedule,Pays 100% Medicare OPPS,100.39,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,72.79,100,,,fee schedule,Pays 100% Medicare OPPS,65.51,378,
Radiologic examination of the foot with 3 or more views,4000022,CDM,320,RC,73630,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,236.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,378,
XR MANDIBLE/LTD LESS 4 VIEWS,4070100,CDM,320,RC,70100,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,236.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,378,
XR STERNUM-AP/LAT/OBLIQUES,4071120,CDM,320,RC,71120,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,236.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,378,
"Radiologic examination of the neck/spine, 2-3 views",4072040,CDM,320,RC,72040,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,236.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,378,
Radiologic examination of the pelvis,4072170,CDM,320,RC,72170,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,236.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,85.55,378,
XR SCAPULA RT,4073010,CDM,320,RC,73010,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,236.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,85.55,378,
Radiologic examination of the shoulder,4073030,CDM,320,RC,73030,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,236.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,378,
XR A C JOINTS,4073050,CDM,320,RC,73050,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,236.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,378,
XR TOTAL EXTRMITY UPPER RT,4073092,CDM,320,RC,73092,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,236.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,85.55,378,
Up to 3 views,4073110,CDM,320,RC,73110,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,236.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,378,
X-ray of the hand with 3 or more views,4073130,CDM,320,RC,73130,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,236.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,378,
Radiologic examination of the lower leg,4073590,CDM,320,RC,73590,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,236.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,378,
XR LOWER EXTRMITY TOTAL RT,4073592,CDM,320,RC,73592,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,236.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,378,
Radiologic examination of the ankle with 3 views,4073610,CDM,320,RC,73610,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,236.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,378,
Radiologic examination of the foot with 3 or more views,4073630,CDM,320,RC,73630,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,236.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,378,
Radiologic examination of the heel,4073650,CDM,320,RC,73650,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,236.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,378,
XR SCAPULA LT,4083010,CDM,320,RC,73010,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,236.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,85.55,378,
Radiologic examination of the shoulder,4083030,CDM,320,RC,73030,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,236.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,378,
XR TOTAL EXTRMITY UPPER LT,4083092,CDM,320,RC,73092,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,236.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,85.55,378,
Up to 3 views,4083110,CDM,320,RC,73110,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,236.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,378,
X-ray of the hand with 3 or more views,4083130,CDM,320,RC,73130,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,236.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,378,
Radiologic examination of the lower leg,4083590,CDM,320,RC,73590,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,236.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,378,
XR LOWER EXTRMITY TOTAL LT,4083592,CDM,320,RC,73592,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,236.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,378,
Radiologic examination of the ankle with 3 views,4083610,CDM,320,RC,73610,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,236.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,378,
Radiologic examination of the heel,4083650,CDM,320,RC,73650,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,236.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,378,
ST SWALLOWING (PER SESSION),5292526,CDM,440,RC,92526,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,81.96,100,,,fee schedule,Pays 100% Medicare OPPS,81.96,100,,,fee schedule,Pays 100% Medicare OPPS,81.96,100,,,fee schedule,Pays 100% Medicare OPPS,105.44,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,83.6,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,81.96,100,,,fee schedule,Pays 100% Medicare OPPS,73.76,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,81.11,100,,,fee schedule,Pays 100% Medicare OPPS,105.44,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,81.96,100,,,fee schedule,Pays 100% Medicare OPPS,73.76,378,
ST APHASIA EVALUATION (PER 1 HOUR),5296105,CDM,440,RC,96105,HCPCS,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,95.28,100,,,fee schedule,Pays 100% Medicare OPPS,95.28,100,,,fee schedule,Pays 100% Medicare OPPS,95.28,100,,,fee schedule,Pays 100% Medicare OPPS,122.3,130,,,fee schedule,Pays 130% Medicare OPPS,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,97.19,102,,,fee schedule,Pays 102% Medicare OPPS,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,95.28,100,,,fee schedule,Pays 100% Medicare OPPS,85.75,90,,,fee schedule,Pays 90% Medicare OPPS,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.08,100,,,fee schedule,Pays 100% Medicare OPPS,122.3,130,,,fee schedule,Pays 130% Medicare OPPS,357,85,,,percent of total billed charges,85% of total billed charges,95.28,100,,,fee schedule,Pays 100% Medicare OPPS,85.55,378,
PNEUMOTHORAX KIT 567032,7905668,CDM,270,RC,,,Outpatient,,,420,336,,357,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,237.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,378,90,,,percent of total billed charges,90% of total billed charges,147,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,288.54,68.7,,,percent of total billed charges,68.7% of total billed charges,336,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,243.6,58,,,percent of total billed charges,58% of total billed charges,85.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,357,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,85.55,378,
BURNS 1 DEGREE LOCAL TX,2016000,CDM,450,RC,16000,HCPCS,Outpatient,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,164.54,102,,,fee schedule,Pays 102% Medicare OPPS,391.5,90,,,percent of total billed charges,90% of total billed charges,152.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,145.18,90,,,fee schedule,Pays 90% Medicare OPPS,252.3,58,,,percent of total billed charges,58% of total billed charges,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.83,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,369.75,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,88.61,391.5,
BURNS W/DEBRIDMENT,2016010,CDM,450,RC,,,Outpatient,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,391.5,90,,,percent of total billed charges,90% of total billed charges,152.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,252.3,58,,,percent of total billed charges,58% of total billed charges,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,369.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,88.61,391.5,
BLADDER IRRIG SIMPLE,2051700,CDM,450,RC,51700,HCPCS,Outpatient,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,239.04,100,,,fee schedule,Pays 100% Medicare OPPS,239.04,100,,,fee schedule,Pays 100% Medicare OPPS,239.04,100,,,fee schedule,Pays 100% Medicare OPPS,245.69,130,,,fee schedule,Pays 130% Medicare OPPS,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,243.81,102,,,fee schedule,Pays 102% Medicare OPPS,391.5,90,,,percent of total billed charges,90% of total billed charges,152.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,239.04,100,,,fee schedule,Pays 100% Medicare OPPS,215.13,90,,,fee schedule,Pays 90% Medicare OPPS,252.3,58,,,percent of total billed charges,58% of total billed charges,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,188.99,100,,,fee schedule,Pays 100% Medicare OPPS,245.69,130,,,fee schedule,Pays 130% Medicare OPPS,369.75,85,,,percent of total billed charges,85% of total billed charges,239.04,100,,,fee schedule,Pays 100% Medicare OPPS,88.61,391.5,
CIPRODEX OTIC SUSPENSION,2600518,CDM,637,RC,,,Outpatient,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,391.5,90,,,percent of total billed charges,90% of total billed charges,152.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,252.3,58,,,percent of total billed charges,58% of total billed charges,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,369.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,88.61,391.5,
...PLASMIN,3000234,CDM,305,RC,85420,HCPCS,Outpatient,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,6.53,100,,,fee schedule,Pays 100% Medicare OPPS,6.53,100,,,fee schedule,Pays 100% Medicare OPPS,6.53,100,,,fee schedule,Pays 100% Medicare OPPS,8.48,130,,,fee schedule,Pays 130% Medicare OPPS,9.89,120.37,,,fee schedule,120.37% of custom fee schedule,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.66,102,,,fee schedule,Pays 102% Medicare OPPS,391.5,90,,,percent of total billed charges,90% of total billed charges,10.29,125.18,,,fee schedule,125.18% of custom fee schedule,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,6.53,100,,,fee schedule,Pays 100% Medicare OPPS,5.87,90,,,fee schedule,Pays 90% Medicare OPPS,252.3,58,,,percent of total billed charges,58% of total billed charges,9.89,120.37,,,fee schedule,120.37% of custom fee schedule,6.53,100,,,fee schedule,Pays 100% Medicare OPPS,8.48,130,,,fee schedule,Pays 130% Medicare OPPS,369.75,85,,,percent of total billed charges,85% of total billed charges,6.53,100,,,fee schedule,Pays 100% Medicare OPPS,5.87,391.5,
PORPHOBILINOGEN RANDOM URINE,3084110,CDM,301,RC,84110,HCPCS,Outpatient,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,8.44,100,,,fee schedule,Pays 100% Medicare OPPS,8.44,100,,,fee schedule,Pays 100% Medicare OPPS,8.44,100,,,fee schedule,Pays 100% Medicare OPPS,10.97,130,,,fee schedule,Pays 130% Medicare OPPS,12.78,120.37,,,fee schedule,120.37% of custom fee schedule,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.6,102,,,fee schedule,Pays 102% Medicare OPPS,391.5,90,,,percent of total billed charges,90% of total billed charges,13.29,125.18,,,fee schedule,125.18% of custom fee schedule,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,8.44,100,,,fee schedule,Pays 100% Medicare OPPS,7.59,90,,,fee schedule,Pays 90% Medicare OPPS,252.3,58,,,percent of total billed charges,58% of total billed charges,12.78,120.37,,,fee schedule,120.37% of custom fee schedule,8.44,100,,,fee schedule,Pays 100% Medicare OPPS,10.97,130,,,fee schedule,Pays 130% Medicare OPPS,369.75,85,,,percent of total billed charges,85% of total billed charges,8.44,100,,,fee schedule,Pays 100% Medicare OPPS,7.59,391.5,
PLASMINOGEN ACTIVITY,3085420,CDM,305,RC,85420,HCPCS,Outpatient,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,6.53,100,,,fee schedule,Pays 100% Medicare OPPS,6.53,100,,,fee schedule,Pays 100% Medicare OPPS,6.53,100,,,fee schedule,Pays 100% Medicare OPPS,8.48,130,,,fee schedule,Pays 130% Medicare OPPS,9.89,120.37,,,fee schedule,120.37% of custom fee schedule,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.66,102,,,fee schedule,Pays 102% Medicare OPPS,391.5,90,,,percent of total billed charges,90% of total billed charges,10.29,125.18,,,fee schedule,125.18% of custom fee schedule,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,6.53,100,,,fee schedule,Pays 100% Medicare OPPS,5.87,90,,,fee schedule,Pays 90% Medicare OPPS,252.3,58,,,percent of total billed charges,58% of total billed charges,9.89,120.37,,,fee schedule,120.37% of custom fee schedule,6.53,100,,,fee schedule,Pays 100% Medicare OPPS,8.48,130,,,fee schedule,Pays 130% Medicare OPPS,369.75,85,,,percent of total billed charges,85% of total billed charges,6.53,100,,,fee schedule,Pays 100% Medicare OPPS,5.87,391.5,
XR NASAL BONES 3 VIEWS,4070160,CDM,320,RC,70160,HCPCS,Outpatient,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,244.47,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,391.5,90,,,percent of total billed charges,90% of total billed charges,152.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,252.3,58,,,percent of total billed charges,58% of total billed charges,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,369.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,391.5,
"2 views, front and back",4071020,CDM,324,RC,71046,HCPCS,Outpatient,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,244.47,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,391.5,90,,,percent of total billed charges,90% of total billed charges,152.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.38,90,,,fee schedule,Pays 90% Medicare OPPS,252.3,58,,,percent of total billed charges,58% of total billed charges,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,369.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.38,391.5,
XR HUMERUS AP/LATERAL RT,4073060,CDM,320,RC,73060,HCPCS,Outpatient,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,244.47,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,391.5,90,,,percent of total billed charges,90% of total billed charges,152.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,252.3,58,,,percent of total billed charges,58% of total billed charges,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,369.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,391.5,
XR HIP AP/LATERAL RT,4073510,CDM,320,RC,73502,HCPCS,Outpatient,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,244.47,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,391.5,90,,,percent of total billed charges,90% of total billed charges,152.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,252.3,58,,,percent of total billed charges,58% of total billed charges,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,369.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,391.5,
XR FEMUR AP/LAT RT,4073550,CDM,320,RC,73552,HCPCS,Outpatient,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,244.47,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,391.5,90,,,percent of total billed charges,90% of total billed charges,152.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,252.3,58,,,percent of total billed charges,58% of total billed charges,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,369.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,391.5,
Radiologic examination of the knee with 1 or 2 views,4073560,CDM,320,RC,73560,HCPCS,Outpatient,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,244.47,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,391.5,90,,,percent of total billed charges,90% of total billed charges,152.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,252.3,58,,,percent of total billed charges,58% of total billed charges,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,369.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,391.5,
Radiologic examination of both knees,4073565,CDM,320,RC,73565,HCPCS,Outpatient,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,244.47,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,391.5,90,,,percent of total billed charges,90% of total billed charges,152.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,252.3,58,,,percent of total billed charges,58% of total billed charges,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,369.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,391.5,
XR HUMERUS AP/LATERAL LT,4083060,CDM,320,RC,73060,HCPCS,Outpatient,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,244.47,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,391.5,90,,,percent of total billed charges,90% of total billed charges,152.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,252.3,58,,,percent of total billed charges,58% of total billed charges,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,369.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,391.5,
XR HIP AP/LATERAL LT,4083510,CDM,320,RC,73502,HCPCS,Outpatient,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,244.47,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,391.5,90,,,percent of total billed charges,90% of total billed charges,152.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,252.3,58,,,percent of total billed charges,58% of total billed charges,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,369.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,391.5,
XR FEMUR AP/LAT LT,4083550,CDM,320,RC,73552,HCPCS,Outpatient,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,244.47,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,391.5,90,,,percent of total billed charges,90% of total billed charges,152.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,252.3,58,,,percent of total billed charges,58% of total billed charges,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,369.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,391.5,
Radiologic examination of the knee with 1 or 2 views,4083560,CDM,320,RC,73560,HCPCS,Outpatient,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,244.47,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,391.5,90,,,percent of total billed charges,90% of total billed charges,152.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,252.3,58,,,percent of total billed charges,58% of total billed charges,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,369.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,391.5,
"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",4300002,CDM,401,RC,77066,HCPCS,Outpatient,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,101.49,100,,,fee schedule,Pays 100% Medicare OPPS,101.49,100,,,fee schedule,Pays 100% Medicare OPPS,101.49,100,,,fee schedule,Pays 100% Medicare OPPS,129.68,130,,,fee schedule,Pays 130% Medicare OPPS,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,244.47,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.52,102,,,fee schedule,Pays 102% Medicare OPPS,391.5,90,,,percent of total billed charges,90% of total billed charges,152.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,101.49,100,,,fee schedule,Pays 100% Medicare OPPS,91.34,90,,,fee schedule,Pays 90% Medicare OPPS,252.3,58,,,percent of total billed charges,58% of total billed charges,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,99.75,100,,,fee schedule,Pays 100% Medicare OPPS,129.68,130,,,fee schedule,Pays 130% Medicare OPPS,369.75,85,,,percent of total billed charges,85% of total billed charges,101.49,100,,,fee schedule,Pays 100% Medicare OPPS,88.61,391.5,
"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",4300003,CDM,401,RC,77065,HCPCS,Outpatient,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,101.74,130,,,fee schedule,Pays 130% Medicare OPPS,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,244.47,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.2,102,,,fee schedule,Pays 102% Medicare OPPS,391.5,90,,,percent of total billed charges,90% of total billed charges,152.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,71.65,90,,,fee schedule,Pays 90% Medicare OPPS,252.3,58,,,percent of total billed charges,58% of total billed charges,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,78.26,100,,,fee schedule,Pays 100% Medicare OPPS,101.74,130,,,fee schedule,Pays 130% Medicare OPPS,369.75,85,,,percent of total billed charges,85% of total billed charges,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,71.65,391.5,
Mammography of both breasts-2 or more views,4300202,CDM,403,RC,77067,HCPCS,Outpatient,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,83.86,100,,,fee schedule,Pays 100% Medicare OPPS,83.86,100,,,fee schedule,Pays 100% Medicare OPPS,83.86,100,,,fee schedule,Pays 100% Medicare OPPS,107.56,130,,,fee schedule,Pays 130% Medicare OPPS,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,244.47,56.5,,,percent of total billed charges,56.5 percent of total billed charges,85.54,102,,,fee schedule,Pays 102% Medicare OPPS,391.5,90,,,percent of total billed charges,90% of total billed charges,152.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,83.86,100,,,fee schedule,Pays 100% Medicare OPPS,75.47,90,,,fee schedule,Pays 90% Medicare OPPS,252.3,58,,,percent of total billed charges,58% of total billed charges,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,82.74,100,,,fee schedule,Pays 100% Medicare OPPS,107.56,130,,,fee schedule,Pays 130% Medicare OPPS,369.75,85,,,percent of total billed charges,85% of total billed charges,83.86,100,,,fee schedule,Pays 100% Medicare OPPS,75.47,391.5,
"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",4300206,CDM,401,RC,77065,HCPCS,Outpatient,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,101.74,130,,,fee schedule,Pays 130% Medicare OPPS,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,244.47,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.2,102,,,fee schedule,Pays 102% Medicare OPPS,391.5,90,,,percent of total billed charges,90% of total billed charges,152.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,71.65,90,,,fee schedule,Pays 90% Medicare OPPS,252.3,58,,,percent of total billed charges,58% of total billed charges,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,78.26,100,,,fee schedule,Pays 100% Medicare OPPS,101.74,130,,,fee schedule,Pays 130% Medicare OPPS,369.75,85,,,percent of total billed charges,85% of total billed charges,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,71.65,391.5,
"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",4302060,CDM,401,RC,77065,HCPCS,Outpatient,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,101.74,130,,,fee schedule,Pays 130% Medicare OPPS,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,244.47,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.2,102,,,fee schedule,Pays 102% Medicare OPPS,391.5,90,,,percent of total billed charges,90% of total billed charges,152.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,71.65,90,,,fee schedule,Pays 90% Medicare OPPS,252.3,58,,,percent of total billed charges,58% of total billed charges,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,78.26,100,,,fee schedule,Pays 100% Medicare OPPS,101.74,130,,,fee schedule,Pays 130% Medicare OPPS,369.75,85,,,percent of total billed charges,85% of total billed charges,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,71.65,391.5,
ANKLE BRACE AIRCAST LT (FIT/ADJ),7905124,CDM,274,RC,L4350,HCPCS,Both,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,391.5,90,,,percent of total billed charges,90% of total billed charges,152.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,252.3,58,,,percent of total billed charges,58% of total billed charges,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,369.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,88.61,391.5,
TWISTER POLYP RETRIEVAL DEVICE,7905545,CDM,270,RC,,,Outpatient,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,391.5,90,,,percent of total billed charges,90% of total billed charges,152.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,252.3,58,,,percent of total billed charges,58% of total billed charges,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,369.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,88.61,391.5,
ROTH RET NET BX00711050,7905565,CDM,270,RC,,,Outpatient,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,391.5,90,,,percent of total billed charges,90% of total billed charges,152.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,252.3,58,,,percent of total billed charges,58% of total billed charges,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,369.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,88.61,391.5,
RESCUENET DGN-538-5,7905586,CDM,272,RC,,,Outpatient,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,391.5,90,,,percent of total billed charges,90% of total billed charges,152.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,252.3,58,,,percent of total billed charges,58% of total billed charges,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,369.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,88.61,391.5,
CATH INTRAN PLUS IUP-400,7905779,CDM,270,RC,,,Outpatient,,,435,348,,369.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,245.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,391.5,90,,,percent of total billed charges,90% of total billed charges,152.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,298.85,68.7,,,percent of total billed charges,68.7% of total billed charges,348,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,252.3,58,,,percent of total billed charges,58% of total billed charges,88.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,369.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,88.61,391.5,
SHAVING OF EPIDERMAL/DERMAL LESION,2011305,CDM,450,RC,11305,HCPCS,Outpatient,,,440,352,,374,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,89.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,164.54,102,,,fee schedule,Pays 102% Medicare OPPS,396,90,,,percent of total billed charges,90% of total billed charges,154,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,302.28,68.7,,,percent of total billed charges,68.7% of total billed charges,352,80,,,percent of total billed charges,80 percent of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,145.18,90,,,fee schedule,Pays 90% Medicare OPPS,255.2,58,,,percent of total billed charges,58% of total billed charges,89.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.83,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,374,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,89.63,396,
DEBRIDEMENT OF NAIL(S) 1-5 ANY METHOD,2011720,CDM,450,RC,,,Outpatient,,,440,352,,374,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,89.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,396,90,,,percent of total billed charges,90% of total billed charges,154,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,302.28,68.7,,,percent of total billed charges,68.7% of total billed charges,352,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,255.2,58,,,percent of total billed charges,58% of total billed charges,89.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,374,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,89.63,396,
REMOVAL EMBEDDED FOREIGN BODY,2041805,CDM,450,RC,,,Outpatient,,,440,352,,374,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,89.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,396,90,,,percent of total billed charges,90% of total billed charges,154,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,302.28,68.7,,,percent of total billed charges,68.7% of total billed charges,352,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,255.2,58,,,percent of total billed charges,58% of total billed charges,89.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,374,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,89.63,396,
"Radiologic examination, elbow; 3 or more views",4073080,CDM,320,RC,73080,HCPCS,Outpatient,,,440,352,,374,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,89.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,247.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,396,90,,,percent of total billed charges,90% of total billed charges,154,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,302.28,68.7,,,percent of total billed charges,68.7% of total billed charges,352,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,255.2,58,,,percent of total billed charges,58% of total billed charges,89.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,374,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,396,
"Radiologic examination, elbow; 3 or more views",4073081,CDM,320,RC,73080,HCPCS,Outpatient,,,440,352,,374,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,89.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,247.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,396,90,,,percent of total billed charges,90% of total billed charges,154,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,302.28,68.7,,,percent of total billed charges,68.7% of total billed charges,352,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,255.2,58,,,percent of total billed charges,58% of total billed charges,89.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,374,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,396,
X-RAY STRESS VIEW,4077071,CDM,250,RC,77071,HCPCS,Outpatient,,,440,352,,374,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,89.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,396,90,,,percent of total billed charges,90% of total billed charges,154,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,302.28,68.7,,,percent of total billed charges,68.7% of total billed charges,352,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,255.2,58,,,percent of total billed charges,58% of total billed charges,89.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,374,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,396,
FINE NEEDLE ASPIR BX W/US GDN EA ADDL LE,4610006,CDM,761,RC,10006,HCPCS,Outpatient,,,440,352,,374,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,89.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,396,90,,,percent of total billed charges,90% of total billed charges,154,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,302.28,68.7,,,percent of total billed charges,68.7% of total billed charges,352,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,255.2,58,,,percent of total billed charges,58% of total billed charges,89.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,374,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,89.63,396,
BIOPSY BREAST ADDL AREA INC US GUIDANNCE,4619084,CDM,761,RC,19084,HCPCS,Outpatient,,,440,352,,374,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,89.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,248.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,396,90,,,percent of total billed charges,90% of total billed charges,154,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,302.28,68.7,,,percent of total billed charges,68.7% of total billed charges,352,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,255.2,58,,,percent of total billed charges,58% of total billed charges,89.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,374,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,89.63,396,
Echo with doppler,5793320,CDM,483,RC,93320,HCPCS,Outpatient,,,440,352,,374,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,89.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,,,,,other,Not reimbursable per contract,396,90,,,percent of total billed charges,90% of total billed charges,154,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,302.28,68.7,,,percent of total billed charges,68.7% of total billed charges,352,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,255.2,58,,,percent of total billed charges,58% of total billed charges,89.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,374,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,89.63,986.63,
....ECHO DOPPLER VELOC MAPPIN,5793325,CDM,483,RC,93325,HCPCS,Outpatient,,,440,352,,374,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,89.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,,,,,other,Not reimbursable per contract,396,90,,,percent of total billed charges,90% of total billed charges,154,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,302.28,68.7,,,percent of total billed charges,68.7% of total billed charges,352,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,255.2,58,,,percent of total billed charges,58% of total billed charges,89.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,374,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,89.63,986.63,
AEROBID (FLUNISOLIDE) MDI INH :,2600150,CDM,250,RC,J7641,HCPCS,Outpatient,,,445,356,,378.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,90.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,251.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,251.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,251.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,251.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,400.5,90,,,percent of total billed charges,90% of total billed charges,155.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,305.72,68.7,,,percent of total billed charges,68.7% of total billed charges,356,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,258.1,58,,,percent of total billed charges,58% of total billed charges,90.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,378.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,90.65,400.5,
XR EXAM ENTIRE SPINE 2/3 VIEWS,4072082,CDM,320,RC,72082,HCPCS,Outpatient,,,445,356,,378.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,90.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,251.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,251.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,251.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,250.09,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,400.5,90,,,percent of total billed charges,90% of total billed charges,155.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,305.72,68.7,,,percent of total billed charges,68.7% of total billed charges,356,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,258.1,58,,,percent of total billed charges,58% of total billed charges,90.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,378.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,400.5,
GASTROSTOMY TUBE 000283,7950224,CDM,270,RC,,,Outpatient,,,445,356,,378.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,90.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,251.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,251.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,251.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,251.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,400.5,90,,,percent of total billed charges,90% of total billed charges,155.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,305.72,68.7,,,percent of total billed charges,68.7% of total billed charges,356,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,258.1,58,,,percent of total billed charges,58% of total billed charges,90.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,378.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,90.65,400.5,
MARKER BREAST BIOPSY MAMMOSTAR 14G,7950301,CDM,272,RC,,,Outpatient,,,445,356,,378.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,90.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,251.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,251.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,251.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,251.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,400.5,90,,,percent of total billed charges,90% of total billed charges,155.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,305.72,68.7,,,percent of total billed charges,68.7% of total billed charges,356,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,258.1,58,,,percent of total billed charges,58% of total billed charges,90.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,378.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,90.65,400.5,
Blood test to measure a type of estrogen in the blood,300799,CDM,301,RC,82670,HCPCS,Outpatient,,,450,360,,382.5,85,,,percent of total billed charges,85% of total billed charges,27.94,100,,,fee schedule,Pays 100% Medicare OPPS,27.94,100,,,fee schedule,Pays 100% Medicare OPPS,27.94,100,,,fee schedule,Pays 100% Medicare OPPS,36.32,130,,,fee schedule,Pays 130% Medicare OPPS,42.3,120.37,,,fee schedule,120.37% of custom fee schedule,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.49,102,,,fee schedule,Pays 102% Medicare OPPS,405,90,,,percent of total billed charges,90% of total billed charges,43.99,125.18,,,fee schedule,125.18% of custom fee schedule,309.15,68.7,,,percent of total billed charges,68.7% of total billed charges,360,80,,,percent of total billed charges,80 percent of total billed charges,27.94,100,,,fee schedule,Pays 100% Medicare OPPS,25.14,90,,,fee schedule,Pays 90% Medicare OPPS,261,58,,,percent of total billed charges,58% of total billed charges,42.3,120.37,,,fee schedule,120.37% of custom fee schedule,27.94,100,,,fee schedule,Pays 100% Medicare OPPS,36.32,130,,,fee schedule,Pays 130% Medicare OPPS,382.5,85,,,percent of total billed charges,85% of total billed charges,27.94,100,,,fee schedule,Pays 100% Medicare OPPS,25.14,405,
SUTURE 0 PROLENE C845G,1570508,CDM,272,RC,,,Outpatient,,,450,360,,382.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,91.67,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,405,90,,,percent of total billed charges,90% of total billed charges,157.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,309.15,68.7,,,percent of total billed charges,68.7% of total billed charges,360,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,261,58,,,percent of total billed charges,58% of total billed charges,91.67,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,382.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,91.67,405,
CYTOLOGY BRUSH RX,1750023,CDM,272,RC,,,Outpatient,,,450,360,,382.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,91.67,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,405,90,,,percent of total billed charges,90% of total billed charges,157.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,309.15,68.7,,,percent of total billed charges,68.7% of total billed charges,360,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,261,58,,,percent of total billed charges,58% of total billed charges,91.67,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,382.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,91.67,405,
EXPLORATION WOUND EXTREMITY,2020103,CDM,450,RC,20103,HCPCS,Outpatient,,,450,360,,382.5,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,91.67,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,570.17,102,,,fee schedule,Pays 102% Medicare OPPS,405,90,,,percent of total billed charges,90% of total billed charges,157.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,309.15,68.7,,,percent of total billed charges,68.7% of total billed charges,360,80,,,percent of total billed charges,80 percent of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,503.1,90,,,fee schedule,Pays 90% Medicare OPPS,261,58,,,percent of total billed charges,58% of total billed charges,91.67,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1318.97,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,382.5,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,91.67,1714.66,
NITROLINGUAL (NITRO) SPR,2603081,CDM,637,RC,,,Outpatient,,,450,360,,382.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,91.67,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,405,90,,,percent of total billed charges,90% of total billed charges,157.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,309.15,68.7,,,percent of total billed charges,68.7% of total billed charges,360,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,261,58,,,percent of total billed charges,58% of total billed charges,91.67,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,382.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,91.67,405,
DENGUE VIRUS IgM ANTIBODY,3000083,CDM,300,RC,86790,HCPCS,Outpatient,,,450,360,,382.5,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.13,102,,,fee schedule,Pays 102% Medicare OPPS,405,90,,,percent of total billed charges,90% of total billed charges,20.28,125.18,,,fee schedule,125.18% of custom fee schedule,309.15,68.7,,,percent of total billed charges,68.7% of total billed charges,360,80,,,percent of total billed charges,80 percent of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,90,,,fee schedule,Pays 90% Medicare OPPS,261,58,,,percent of total billed charges,58% of total billed charges,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,382.5,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,405,
RITALIN LEVEL,3000265,CDM,301,RC,80299,HCPCS,Outpatient,,,450,360,,382.5,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.01,102,,,fee schedule,Pays 102% Medicare OPPS,405,90,,,percent of total billed charges,90% of total billed charges,18.95,125.18,,,fee schedule,125.18% of custom fee schedule,309.15,68.7,,,percent of total billed charges,68.7% of total billed charges,360,80,,,percent of total billed charges,80 percent of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,90,,,fee schedule,Pays 90% Medicare OPPS,261,58,,,percent of total billed charges,58% of total billed charges,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,382.5,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,405,
"Blood test, comprehensive group of blood chemicals",3000392,CDM,301,RC,80053,HCPCS,Outpatient,,,450,360,,382.5,85,,,percent of total billed charges,85% of total billed charges,10.56,100,,,fee schedule,Pays 100% Medicare OPPS,10.56,100,,,fee schedule,Pays 100% Medicare OPPS,10.56,100,,,fee schedule,Pays 100% Medicare OPPS,13.72,130,,,fee schedule,Pays 130% Medicare OPPS,16,120.37,,,fee schedule,120.37% of custom fee schedule,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,10.77,102,,,fee schedule,Pays 102% Medicare OPPS,405,90,,,percent of total billed charges,90% of total billed charges,16.64,125.18,,,fee schedule,125.18% of custom fee schedule,309.15,68.7,,,percent of total billed charges,68.7% of total billed charges,360,80,,,percent of total billed charges,80 percent of total billed charges,10.56,100,,,fee schedule,Pays 100% Medicare OPPS,9.5,90,,,fee schedule,Pays 90% Medicare OPPS,261,58,,,percent of total billed charges,58% of total billed charges,16,120.37,,,fee schedule,120.37% of custom fee schedule,10.56,100,,,fee schedule,Pays 100% Medicare OPPS,13.72,130,,,fee schedule,Pays 130% Medicare OPPS,382.5,85,,,percent of total billed charges,85% of total billed charges,10.56,100,,,fee schedule,Pays 100% Medicare OPPS,9.5,405,
Blood test to measure a type of estrogen in the blood,3082670,CDM,301,RC,82670,HCPCS,Outpatient,,,450,360,,382.5,85,,,percent of total billed charges,85% of total billed charges,27.94,100,,,fee schedule,Pays 100% Medicare OPPS,27.94,100,,,fee schedule,Pays 100% Medicare OPPS,27.94,100,,,fee schedule,Pays 100% Medicare OPPS,36.32,130,,,fee schedule,Pays 130% Medicare OPPS,42.3,120.37,,,fee schedule,120.37% of custom fee schedule,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.49,102,,,fee schedule,Pays 102% Medicare OPPS,405,90,,,percent of total billed charges,90% of total billed charges,43.99,125.18,,,fee schedule,125.18% of custom fee schedule,309.15,68.7,,,percent of total billed charges,68.7% of total billed charges,360,80,,,percent of total billed charges,80 percent of total billed charges,27.94,100,,,fee schedule,Pays 100% Medicare OPPS,25.14,90,,,fee schedule,Pays 90% Medicare OPPS,261,58,,,percent of total billed charges,58% of total billed charges,42.3,120.37,,,fee schedule,120.37% of custom fee schedule,27.94,100,,,fee schedule,Pays 100% Medicare OPPS,36.32,130,,,fee schedule,Pays 130% Medicare OPPS,382.5,85,,,percent of total billed charges,85% of total billed charges,27.94,100,,,fee schedule,Pays 100% Medicare OPPS,25.14,405,
DENGUE VIRUS IgG ANTIBODY,3086790,CDM,300,RC,86790,HCPCS,Outpatient,,,450,360,,382.5,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,254.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.13,102,,,fee schedule,Pays 102% Medicare OPPS,405,90,,,percent of total billed charges,90% of total billed charges,20.28,125.18,,,fee schedule,125.18% of custom fee schedule,309.15,68.7,,,percent of total billed charges,68.7% of total billed charges,360,80,,,percent of total billed charges,80 percent of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,90,,,fee schedule,Pays 90% Medicare OPPS,261,58,,,percent of total billed charges,58% of total billed charges,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,382.5,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,405,
JAGWIRE ST .025 450CM,1750033,CDM,272,RC,,,Outpatient,,,460,368,,391,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,259.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,259.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,259.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,259.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,414,90,,,percent of total billed charges,90% of total billed charges,161,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,316.02,68.7,,,percent of total billed charges,68.7% of total billed charges,368,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,266.8,58,,,percent of total billed charges,58% of total billed charges,93.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,391,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,93.7,414,
BURN SMALL DSG/DEBRIDMENT,2016021,CDM,450,RC,16020,HCPCS,Outpatient,,,460,368,,391,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,93.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,259.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,259.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,259.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,259.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,164.54,102,,,fee schedule,Pays 102% Medicare OPPS,414,90,,,percent of total billed charges,90% of total billed charges,161,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,316.02,68.7,,,percent of total billed charges,68.7% of total billed charges,368,80,,,percent of total billed charges,80 percent of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,145.18,90,,,fee schedule,Pays 90% Medicare OPPS,266.8,58,,,percent of total billed charges,58% of total billed charges,93.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.83,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,391,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,93.7,414,
DISLOC ANKLE TX,2027840,CDM,450,RC,27840,HCPCS,Outpatient,,,460,368,,391,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,93.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,259.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,259.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,259.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,259.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,188.85,102,,,fee schedule,Pays 102% Medicare OPPS,414,90,,,percent of total billed charges,90% of total billed charges,161,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,316.02,68.7,,,percent of total billed charges,68.7% of total billed charges,368,80,,,percent of total billed charges,80 percent of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,166.63,90,,,fee schedule,Pays 90% Medicare OPPS,266.8,58,,,percent of total billed charges,58% of total billed charges,93.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,182.08,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,391,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,93.7,414,
CATHFLO (ALTEPLASE) 2MG INJ,2600193,CDM,250,RC,,,Outpatient,,,460,368,,391,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,259.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,259.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,259.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,259.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,414,90,,,percent of total billed charges,90% of total billed charges,161,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,316.02,68.7,,,percent of total billed charges,68.7% of total billed charges,368,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,266.8,58,,,percent of total billed charges,58% of total billed charges,93.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,391,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,93.7,414,
PROTOPAM (PRALIDOXIME) INJ 1GM,2601382,CDM,636,RC,,,Both,,,460,368,,391,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,414,90,,,percent of total billed charges,90% of total billed charges,161,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,316.02,68.7,,,percent of total billed charges,68.7% of total billed charges,368,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,266.8,58,,,percent of total billed charges,58% of total billed charges,93.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,391,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,93.7,414,
ARTHROSCOPY PK IV,7905550,CDM,270,RC,,,Outpatient,,,460,368,,391,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,259.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,259.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,259.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,259.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,414,90,,,percent of total billed charges,90% of total billed charges,161,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,316.02,68.7,,,percent of total billed charges,68.7% of total billed charges,368,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,266.8,58,,,percent of total billed charges,58% of total billed charges,93.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,391,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,93.7,414,
MARKER BREAST BIOPSY HYDROMARK T1,7950299,CDM,272,RC,,,Outpatient,,,460,368,,391,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,93.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,259.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,259.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,259.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,259.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,414,90,,,percent of total billed charges,90% of total billed charges,161,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,316.02,68.7,,,percent of total billed charges,68.7% of total billed charges,368,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,266.8,58,,,percent of total billed charges,58% of total billed charges,93.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,391,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,93.7,414,
ADVAIR (FLUTIC/SALMETEROL)MDI INH 500-50,2605145,CDM,250,RC,,,Outpatient,,,465,372,,395.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,94.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,418.5,90,,,percent of total billed charges,90% of total billed charges,162.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,319.46,68.7,,,percent of total billed charges,68.7% of total billed charges,372,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,269.7,58,,,percent of total billed charges,58% of total billed charges,94.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,395.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,94.72,418.5,
TIAGABINE,3000118,CDM,301,RC,80199,HCPCS,Outpatient,,,465,372,,395.25,85,,,percent of total billed charges,85% of total billed charges,27.11,100,,,fee schedule,Pays 100% Medicare OPPS,27.11,100,,,fee schedule,Pays 100% Medicare OPPS,27.11,100,,,fee schedule,Pays 100% Medicare OPPS,35.24,130,,,fee schedule,Pays 130% Medicare OPPS,7.88,120.37,,,fee schedule,120.37% of custom fee schedule,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,27.65,102,,,fee schedule,Pays 102% Medicare OPPS,418.5,90,,,percent of total billed charges,90% of total billed charges,8.2,125.18,,,fee schedule,125.18% of custom fee schedule,319.46,68.7,,,percent of total billed charges,68.7% of total billed charges,372,80,,,percent of total billed charges,80 percent of total billed charges,27.11,100,,,fee schedule,Pays 100% Medicare OPPS,24.39,90,,,fee schedule,Pays 90% Medicare OPPS,269.7,58,,,percent of total billed charges,58% of total billed charges,7.88,120.37,,,fee schedule,120.37% of custom fee schedule,27.11,100,,,fee schedule,Pays 100% Medicare OPPS,35.24,130,,,fee schedule,Pays 130% Medicare OPPS,395.25,85,,,percent of total billed charges,85% of total billed charges,27.11,100,,,fee schedule,Pays 100% Medicare OPPS,7.88,418.5,
ZOLOFT LEVEL,3000338,CDM,301,RC,80332,HCPCS,Outpatient,,,465,372,,395.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,94.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,418.5,90,,,percent of total billed charges,90% of total billed charges,162.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,319.46,68.7,,,percent of total billed charges,68.7% of total billed charges,372,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,269.7,58,,,percent of total billed charges,58% of total billed charges,94.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,395.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,94.72,418.5,
.ANTI ACETYLCHOLINE RECPT,3000348,CDM,302,RC,83519,HCPCS,Outpatient,,,465,372,,395.25,85,,,percent of total billed charges,85% of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,23.92,130,,,fee schedule,Pays 130% Medicare OPPS,20.45,120.37,,,fee schedule,120.37% of custom fee schedule,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.76,102,,,fee schedule,Pays 102% Medicare OPPS,418.5,90,,,percent of total billed charges,90% of total billed charges,21.27,125.18,,,fee schedule,125.18% of custom fee schedule,319.46,68.7,,,percent of total billed charges,68.7% of total billed charges,372,80,,,percent of total billed charges,80 percent of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.55,90,,,fee schedule,Pays 90% Medicare OPPS,269.7,58,,,percent of total billed charges,58% of total billed charges,20.45,120.37,,,fee schedule,120.37% of custom fee schedule,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,23.92,130,,,fee schedule,Pays 130% Medicare OPPS,395.25,85,,,percent of total billed charges,85% of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.55,418.5,
3RD CYCLOSPORINE,3080158,CDM,301,RC,80158,HCPCS,Outpatient,,,465,372,,395.25,85,,,percent of total billed charges,85% of total billed charges,18.05,100,,,fee schedule,Pays 100% Medicare OPPS,18.05,100,,,fee schedule,Pays 100% Medicare OPPS,18.05,100,,,fee schedule,Pays 100% Medicare OPPS,23.46,130,,,fee schedule,Pays 130% Medicare OPPS,9.03,120.37,,,fee schedule,120.37% of custom fee schedule,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.41,102,,,fee schedule,Pays 102% Medicare OPPS,418.5,90,,,percent of total billed charges,90% of total billed charges,9.39,125.18,,,fee schedule,125.18% of custom fee schedule,319.46,68.7,,,percent of total billed charges,68.7% of total billed charges,372,80,,,percent of total billed charges,80 percent of total billed charges,18.05,100,,,fee schedule,Pays 100% Medicare OPPS,16.24,90,,,fee schedule,Pays 90% Medicare OPPS,269.7,58,,,percent of total billed charges,58% of total billed charges,9.03,120.37,,,fee schedule,120.37% of custom fee schedule,18.05,100,,,fee schedule,Pays 100% Medicare OPPS,23.46,130,,,fee schedule,Pays 130% Medicare OPPS,395.25,85,,,percent of total billed charges,85% of total billed charges,18.05,100,,,fee schedule,Pays 100% Medicare OPPS,9.03,418.5,
ACTH,3082024,CDM,301,RC,82024,HCPCS,Outpatient,,,465,372,,395.25,85,,,percent of total billed charges,85% of total billed charges,38.61,100,,,fee schedule,Pays 100% Medicare OPPS,38.61,100,,,fee schedule,Pays 100% Medicare OPPS,38.61,100,,,fee schedule,Pays 100% Medicare OPPS,50.2,130,,,fee schedule,Pays 130% Medicare OPPS,58.46,120.37,,,fee schedule,120.37% of custom fee schedule,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.39,102,,,fee schedule,Pays 102% Medicare OPPS,418.5,90,,,percent of total billed charges,90% of total billed charges,60.8,125.18,,,fee schedule,125.18% of custom fee schedule,319.46,68.7,,,percent of total billed charges,68.7% of total billed charges,372,80,,,percent of total billed charges,80 percent of total billed charges,38.61,100,,,fee schedule,Pays 100% Medicare OPPS,34.75,90,,,fee schedule,Pays 90% Medicare OPPS,269.7,58,,,percent of total billed charges,58% of total billed charges,58.46,120.37,,,fee schedule,120.37% of custom fee schedule,38.61,100,,,fee schedule,Pays 100% Medicare OPPS,50.2,130,,,fee schedule,Pays 130% Medicare OPPS,395.25,85,,,percent of total billed charges,85% of total billed charges,38.61,100,,,fee schedule,Pays 100% Medicare OPPS,34.75,418.5,
CITRATE URINE,3082507,CDM,301,RC,82507,HCPCS,Outpatient,,,465,372,,395.25,85,,,percent of total billed charges,85% of total billed charges,27.8,100,,,fee schedule,Pays 100% Medicare OPPS,27.8,100,,,fee schedule,Pays 100% Medicare OPPS,27.8,100,,,fee schedule,Pays 100% Medicare OPPS,36.14,130,,,fee schedule,Pays 130% Medicare OPPS,42.09,120.37,,,fee schedule,120.37% of custom fee schedule,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,28.35,102,,,fee schedule,Pays 102% Medicare OPPS,418.5,90,,,percent of total billed charges,90% of total billed charges,43.78,125.18,,,fee schedule,125.18% of custom fee schedule,319.46,68.7,,,percent of total billed charges,68.7% of total billed charges,372,80,,,percent of total billed charges,80 percent of total billed charges,27.8,100,,,fee schedule,Pays 100% Medicare OPPS,25.02,90,,,fee schedule,Pays 90% Medicare OPPS,269.7,58,,,percent of total billed charges,58% of total billed charges,42.09,120.37,,,fee schedule,120.37% of custom fee schedule,27.8,100,,,fee schedule,Pays 100% Medicare OPPS,36.14,130,,,fee schedule,Pays 130% Medicare OPPS,395.25,85,,,percent of total billed charges,85% of total billed charges,27.8,100,,,fee schedule,Pays 100% Medicare OPPS,25.02,418.5,
CRYOFIBRINOGEN,3082585,CDM,301,RC,82585,HCPCS,Outpatient,,,465,372,,395.25,85,,,percent of total billed charges,85% of total billed charges,14.14,100,,,fee schedule,Pays 100% Medicare OPPS,14.14,100,,,fee schedule,Pays 100% Medicare OPPS,14.14,100,,,fee schedule,Pays 100% Medicare OPPS,18.38,130,,,fee schedule,Pays 130% Medicare OPPS,12.98,120.37,,,fee schedule,120.37% of custom fee schedule,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.42,102,,,fee schedule,Pays 102% Medicare OPPS,418.5,90,,,percent of total billed charges,90% of total billed charges,13.49,125.18,,,fee schedule,125.18% of custom fee schedule,319.46,68.7,,,percent of total billed charges,68.7% of total billed charges,372,80,,,percent of total billed charges,80 percent of total billed charges,14.14,100,,,fee schedule,Pays 100% Medicare OPPS,12.72,90,,,fee schedule,Pays 90% Medicare OPPS,269.7,58,,,percent of total billed charges,58% of total billed charges,12.98,120.37,,,fee schedule,120.37% of custom fee schedule,14.14,100,,,fee schedule,Pays 100% Medicare OPPS,18.38,130,,,fee schedule,Pays 130% Medicare OPPS,395.25,85,,,percent of total billed charges,85% of total billed charges,14.14,100,,,fee schedule,Pays 100% Medicare OPPS,12.72,418.5,
"VITAMIN D (1,25 Di) D2",3082652,CDM,301,RC,82652,HCPCS,Outpatient,,,465,372,,395.25,85,,,percent of total billed charges,85% of total billed charges,38.5,100,,,fee schedule,Pays 100% Medicare OPPS,38.5,100,,,fee schedule,Pays 100% Medicare OPPS,38.5,100,,,fee schedule,Pays 100% Medicare OPPS,50.05,130,,,fee schedule,Pays 130% Medicare OPPS,58.26,120.37,,,fee schedule,120.37% of custom fee schedule,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,39.27,102,,,fee schedule,Pays 102% Medicare OPPS,418.5,90,,,percent of total billed charges,90% of total billed charges,60.59,125.18,,,fee schedule,125.18% of custom fee schedule,319.46,68.7,,,percent of total billed charges,68.7% of total billed charges,372,80,,,percent of total billed charges,80 percent of total billed charges,38.5,100,,,fee schedule,Pays 100% Medicare OPPS,34.65,90,,,fee schedule,Pays 90% Medicare OPPS,269.7,58,,,percent of total billed charges,58% of total billed charges,58.26,120.37,,,fee schedule,120.37% of custom fee schedule,38.5,100,,,fee schedule,Pays 100% Medicare OPPS,50.05,130,,,fee schedule,Pays 130% Medicare OPPS,395.25,85,,,percent of total billed charges,85% of total billed charges,38.5,100,,,fee schedule,Pays 100% Medicare OPPS,34.65,418.5,
.ACID PHOS PROSTATIC,3084066,CDM,301,RC,84066,HCPCS,Outpatient,,,465,372,,395.25,85,,,percent of total billed charges,85% of total billed charges,9.66,100,,,fee schedule,Pays 100% Medicare OPPS,9.66,100,,,fee schedule,Pays 100% Medicare OPPS,9.66,100,,,fee schedule,Pays 100% Medicare OPPS,12.55,130,,,fee schedule,Pays 130% Medicare OPPS,14.62,120.37,,,fee schedule,120.37% of custom fee schedule,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,9.85,102,,,fee schedule,Pays 102% Medicare OPPS,418.5,90,,,percent of total billed charges,90% of total billed charges,15.21,125.18,,,fee schedule,125.18% of custom fee schedule,319.46,68.7,,,percent of total billed charges,68.7% of total billed charges,372,80,,,percent of total billed charges,80 percent of total billed charges,9.66,100,,,fee schedule,Pays 100% Medicare OPPS,8.69,90,,,fee schedule,Pays 90% Medicare OPPS,269.7,58,,,percent of total billed charges,58% of total billed charges,14.62,120.37,,,fee schedule,120.37% of custom fee schedule,9.66,100,,,fee schedule,Pays 100% Medicare OPPS,12.55,130,,,fee schedule,Pays 130% Medicare OPPS,395.25,85,,,percent of total billed charges,85% of total billed charges,9.66,100,,,fee schedule,Pays 100% Medicare OPPS,8.69,418.5,
3RD ACETYLCHOLINE RECEPTOR BINDING AB,3084238,CDM,301,RC,83519,HCPCS,Outpatient,,,465,372,,395.25,85,,,percent of total billed charges,85% of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,23.92,130,,,fee schedule,Pays 130% Medicare OPPS,20.45,120.37,,,fee schedule,120.37% of custom fee schedule,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.76,102,,,fee schedule,Pays 102% Medicare OPPS,418.5,90,,,percent of total billed charges,90% of total billed charges,21.27,125.18,,,fee schedule,125.18% of custom fee schedule,319.46,68.7,,,percent of total billed charges,68.7% of total billed charges,372,80,,,percent of total billed charges,80 percent of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.55,90,,,fee schedule,Pays 90% Medicare OPPS,269.7,58,,,percent of total billed charges,58% of total billed charges,20.45,120.37,,,fee schedule,120.37% of custom fee schedule,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,23.92,130,,,fee schedule,Pays 130% Medicare OPPS,395.25,85,,,percent of total billed charges,85% of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.55,418.5,
VASOACTIVE INTESTINAL PREP,3084586,CDM,301,RC,84586,HCPCS,Outpatient,,,465,372,,395.25,85,,,percent of total billed charges,85% of total billed charges,35.33,100,,,fee schedule,Pays 100% Medicare OPPS,35.33,100,,,fee schedule,Pays 100% Medicare OPPS,35.33,100,,,fee schedule,Pays 100% Medicare OPPS,45.92,130,,,fee schedule,Pays 130% Medicare OPPS,53.48,120.37,,,fee schedule,120.37% of custom fee schedule,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,36.03,102,,,fee schedule,Pays 102% Medicare OPPS,418.5,90,,,percent of total billed charges,90% of total billed charges,55.62,125.18,,,fee schedule,125.18% of custom fee schedule,319.46,68.7,,,percent of total billed charges,68.7% of total billed charges,372,80,,,percent of total billed charges,80 percent of total billed charges,35.33,100,,,fee schedule,Pays 100% Medicare OPPS,31.79,90,,,fee schedule,Pays 90% Medicare OPPS,269.7,58,,,percent of total billed charges,58% of total billed charges,53.48,120.37,,,fee schedule,120.37% of custom fee schedule,35.33,100,,,fee schedule,Pays 100% Medicare OPPS,45.92,130,,,fee schedule,Pays 130% Medicare OPPS,395.25,85,,,percent of total billed charges,85% of total billed charges,35.33,100,,,fee schedule,Pays 100% Medicare OPPS,31.79,418.5,
C REACTIVE PRTN(ULTR SENS,3086141,CDM,302,RC,86141,HCPCS,Outpatient,,,465,372,,395.25,85,,,percent of total billed charges,85% of total billed charges,12.95,100,,,fee schedule,Pays 100% Medicare OPPS,12.95,100,,,fee schedule,Pays 100% Medicare OPPS,12.95,100,,,fee schedule,Pays 100% Medicare OPPS,16.83,130,,,fee schedule,Pays 130% Medicare OPPS,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.2,102,,,fee schedule,Pays 102% Medicare OPPS,418.5,90,,,percent of total billed charges,90% of total billed charges,20.38,125.18,,,fee schedule,125.18% of custom fee schedule,319.46,68.7,,,percent of total billed charges,68.7% of total billed charges,372,80,,,percent of total billed charges,80 percent of total billed charges,12.95,100,,,fee schedule,Pays 100% Medicare OPPS,11.65,90,,,fee schedule,Pays 90% Medicare OPPS,269.7,58,,,percent of total billed charges,58% of total billed charges,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,12.95,100,,,fee schedule,Pays 100% Medicare OPPS,16.83,130,,,fee schedule,Pays 130% Medicare OPPS,395.25,85,,,percent of total billed charges,85% of total billed charges,12.95,100,,,fee schedule,Pays 100% Medicare OPPS,11.65,418.5,
3 views,4007102,CDM,324,RC,71047,HCPCS,Outpatient,,,465,372,,395.25,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,94.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,261.33,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,418.5,90,,,percent of total billed charges,90% of total billed charges,162.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,319.46,68.7,,,percent of total billed charges,68.7% of total billed charges,372,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,269.7,58,,,percent of total billed charges,58% of total billed charges,94.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,395.25,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,418.5,
XR SIALOGRAPHY,4070390,CDM,324,RC,70390,HCPCS,Outpatient,,,465,372,,395.25,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,94.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,261.33,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,418.5,90,,,percent of total billed charges,90% of total billed charges,162.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,319.46,68.7,,,percent of total billed charges,68.7% of total billed charges,372,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,269.7,58,,,percent of total billed charges,58% of total billed charges,94.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,395.25,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,94.72,418.5,
ECHO LIMITED STUDY,5793308,CDM,483,RC,93308,HCPCS,Outpatient,,,465,372,,395.25,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,94.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,418.5,90,,,percent of total billed charges,90% of total billed charges,162.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,319.46,68.7,,,percent of total billed charges,68.7% of total billed charges,372,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,269.7,58,,,percent of total billed charges,58% of total billed charges,94.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,395.25,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,94.72,986.63,
IRRIGATION OF IMPLANTED VENOUS ACCESS,1596523,CDM,761,RC,96523,HCPCS,Outpatient,,,470,376,,399.5,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,50,100,,,fee schedule,Pays 100% Medicare OPPS,65.72,130,,,fee schedule,Pays 130% Medicare OPPS,95.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,265.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,265.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,265.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,265.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,51,102,,,fee schedule,Pays 102% Medicare OPPS,423,90,,,percent of total billed charges,90% of total billed charges,164.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,322.89,68.7,,,percent of total billed charges,68.7% of total billed charges,376,80,,,percent of total billed charges,80 percent of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,45,90,,,fee schedule,Pays 90% Medicare OPPS,272.6,58,,,percent of total billed charges,58% of total billed charges,95.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,50.55,100,,,fee schedule,Pays 100% Medicare OPPS,65.72,130,,,fee schedule,Pays 130% Medicare OPPS,399.5,85,,,percent of total billed charges,85% of total billed charges,50,100,,,fee schedule,Pays 100% Medicare OPPS,45,423,
CONTROL NASAL HEMORRAHAGE,2030905,CDM,450,RC,30905,HCPCS,Outpatient,,,475,380,,403.75,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,96.76,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,268.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,268.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,268.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,268.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,427.5,90,,,percent of total billed charges,90% of total billed charges,166.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,326.33,68.7,,,percent of total billed charges,68.7% of total billed charges,380,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,275.5,58,,,percent of total billed charges,58% of total billed charges,96.76,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,403.75,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,427.5,
ALPHA-1-ANTITRYPSIN STOOL,3000611,CDM,301,RC,82103,HCPCS,Outpatient,,,475,380,,403.75,85,,,percent of total billed charges,85% of total billed charges,13.44,100,,,fee schedule,Pays 100% Medicare OPPS,13.44,100,,,fee schedule,Pays 100% Medicare OPPS,13.44,100,,,fee schedule,Pays 100% Medicare OPPS,17.47,130,,,fee schedule,Pays 130% Medicare OPPS,20.33,120.37,,,fee schedule,120.37% of custom fee schedule,268.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,268.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,268.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,268.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.7,102,,,fee schedule,Pays 102% Medicare OPPS,427.5,90,,,percent of total billed charges,90% of total billed charges,21.14,125.18,,,fee schedule,125.18% of custom fee schedule,326.33,68.7,,,percent of total billed charges,68.7% of total billed charges,380,80,,,percent of total billed charges,80 percent of total billed charges,13.44,100,,,fee schedule,Pays 100% Medicare OPPS,12.09,90,,,fee schedule,Pays 90% Medicare OPPS,275.5,58,,,percent of total billed charges,58% of total billed charges,20.33,120.37,,,fee schedule,120.37% of custom fee schedule,13.44,100,,,fee schedule,Pays 100% Medicare OPPS,17.47,130,,,fee schedule,Pays 130% Medicare OPPS,403.75,85,,,percent of total billed charges,85% of total billed charges,13.44,100,,,fee schedule,Pays 100% Medicare OPPS,12.09,427.5,
Blood test to diagnose rheumatoid arthritis,3086200,CDM,300,RC,86200,HCPCS,Outpatient,,,475,380,,403.75,85,,,percent of total billed charges,85% of total billed charges,12.95,100,,,fee schedule,Pays 100% Medicare OPPS,12.95,100,,,fee schedule,Pays 100% Medicare OPPS,12.95,100,,,fee schedule,Pays 100% Medicare OPPS,16.83,130,,,fee schedule,Pays 130% Medicare OPPS,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,268.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,268.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,268.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,268.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.2,102,,,fee schedule,Pays 102% Medicare OPPS,427.5,90,,,percent of total billed charges,90% of total billed charges,20.38,125.18,,,fee schedule,125.18% of custom fee schedule,326.33,68.7,,,percent of total billed charges,68.7% of total billed charges,380,80,,,percent of total billed charges,80 percent of total billed charges,12.95,100,,,fee schedule,Pays 100% Medicare OPPS,11.65,90,,,fee schedule,Pays 90% Medicare OPPS,275.5,58,,,percent of total billed charges,58% of total billed charges,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,12.95,100,,,fee schedule,Pays 100% Medicare OPPS,16.83,130,,,fee schedule,Pays 130% Medicare OPPS,403.75,85,,,percent of total billed charges,85% of total billed charges,12.95,100,,,fee schedule,Pays 100% Medicare OPPS,11.65,427.5,
Test to measure arterial blood gases,5582803,CDM,301,RC,82803,HCPCS,Outpatient,,,475,380,,403.75,85,,,percent of total billed charges,85% of total billed charges,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,33.89,130,,,fee schedule,Pays 130% Medicare OPPS,29.3,120.37,,,fee schedule,120.37% of custom fee schedule,268.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,268.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,268.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,268.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,26.59,102,,,fee schedule,Pays 102% Medicare OPPS,427.5,90,,,percent of total billed charges,90% of total billed charges,30.47,125.18,,,fee schedule,125.18% of custom fee schedule,326.33,68.7,,,percent of total billed charges,68.7% of total billed charges,380,80,,,percent of total billed charges,80 percent of total billed charges,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,23.46,90,,,fee schedule,Pays 90% Medicare OPPS,275.5,58,,,percent of total billed charges,58% of total billed charges,29.3,120.37,,,fee schedule,120.37% of custom fee schedule,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,33.89,130,,,fee schedule,Pays 130% Medicare OPPS,403.75,85,,,percent of total billed charges,85% of total billed charges,26.07,100,,,fee schedule,Pays 100% Medicare OPPS,23.46,427.5,
BLADE TORPEDO SHAVER 4.0MM X 13CM,1570817,CDM,272,RC,,,Outpatient,,,480,384,,408,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,97.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,271.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,271.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,271.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,271.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,432,90,,,percent of total billed charges,90% of total billed charges,168,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,329.76,68.7,,,percent of total billed charges,68.7% of total billed charges,384,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,278.4,58,,,percent of total billed charges,58% of total billed charges,97.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,408,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,97.78,432,
PRIMACOR (MILRINONE) INJ 20MG,2605046,CDM,250,RC,,,Outpatient,,,480,384,,408,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,97.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,271.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,271.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,271.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,271.2,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,432,90,,,percent of total billed charges,90% of total billed charges,168,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,329.76,68.7,,,percent of total billed charges,68.7% of total billed charges,384,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,278.4,58,,,percent of total billed charges,58% of total billed charges,97.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,408,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,97.78,432,
INJ SNGLE TNDN SHTH LIGAM,2020550,CDM,450,RC,,,Outpatient,,,485,388,,412.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,98.79,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,436.5,90,,,percent of total billed charges,90% of total billed charges,169.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,333.2,68.7,,,percent of total billed charges,68.7% of total billed charges,388,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,281.3,58,,,percent of total billed charges,58% of total billed charges,98.79,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,412.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,98.79,436.5,
CD-4/CD-8 COUNT ABSOLUTE,3000040,CDM,302,RC,86360,HCPCS,Outpatient,,,485,388,,412.25,85,,,percent of total billed charges,85% of total billed charges,46.98,100,,,fee schedule,Pays 100% Medicare OPPS,46.98,100,,,fee schedule,Pays 100% Medicare OPPS,46.98,100,,,fee schedule,Pays 100% Medicare OPPS,61.07,130,,,fee schedule,Pays 130% Medicare OPPS,71.13,120.37,,,fee schedule,120.37% of custom fee schedule,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,47.91,102,,,fee schedule,Pays 102% Medicare OPPS,436.5,90,,,percent of total billed charges,90% of total billed charges,73.97,125.18,,,fee schedule,125.18% of custom fee schedule,333.2,68.7,,,percent of total billed charges,68.7% of total billed charges,388,80,,,percent of total billed charges,80 percent of total billed charges,46.98,100,,,fee schedule,Pays 100% Medicare OPPS,42.28,90,,,fee schedule,Pays 90% Medicare OPPS,281.3,58,,,percent of total billed charges,58% of total billed charges,71.13,120.37,,,fee schedule,120.37% of custom fee schedule,46.98,100,,,fee schedule,Pays 100% Medicare OPPS,61.07,130,,,fee schedule,Pays 130% Medicare OPPS,412.25,85,,,percent of total billed charges,85% of total billed charges,46.98,100,,,fee schedule,Pays 100% Medicare OPPS,42.28,436.5,
3RD WEST NILE IGG VIRUS (CSF),3000333,CDM,302,RC,86789,HCPCS,Outpatient,,,485,388,,412.25,85,,,percent of total billed charges,85% of total billed charges,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.7,130,,,fee schedule,Pays 130% Medicare OPPS,17.61,120.37,,,fee schedule,120.37% of custom fee schedule,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.67,102,,,fee schedule,Pays 102% Medicare OPPS,436.5,90,,,percent of total billed charges,90% of total billed charges,18.31,125.18,,,fee schedule,125.18% of custom fee schedule,333.2,68.7,,,percent of total billed charges,68.7% of total billed charges,388,80,,,percent of total billed charges,80 percent of total billed charges,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.95,90,,,fee schedule,Pays 90% Medicare OPPS,281.3,58,,,percent of total billed charges,58% of total billed charges,17.61,120.37,,,fee schedule,120.37% of custom fee schedule,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.7,130,,,fee schedule,Pays 130% Medicare OPPS,412.25,85,,,percent of total billed charges,85% of total billed charges,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.95,436.5,
3RD WEST NILE IGG VIRUS(SERUM),3000334,CDM,302,RC,86789,HCPCS,Outpatient,,,485,388,,412.25,85,,,percent of total billed charges,85% of total billed charges,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.7,130,,,fee schedule,Pays 130% Medicare OPPS,17.61,120.37,,,fee schedule,120.37% of custom fee schedule,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.67,102,,,fee schedule,Pays 102% Medicare OPPS,436.5,90,,,percent of total billed charges,90% of total billed charges,18.31,125.18,,,fee schedule,125.18% of custom fee schedule,333.2,68.7,,,percent of total billed charges,68.7% of total billed charges,388,80,,,percent of total billed charges,80 percent of total billed charges,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.95,90,,,fee schedule,Pays 90% Medicare OPPS,281.3,58,,,percent of total billed charges,58% of total billed charges,17.61,120.37,,,fee schedule,120.37% of custom fee schedule,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.7,130,,,fee schedule,Pays 130% Medicare OPPS,412.25,85,,,percent of total billed charges,85% of total billed charges,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.95,436.5,
3RD WEST NILE VIRUS ABS(SERUM),3000547,CDM,302,RC,86789,HCPCS,Outpatient,,,485,388,,412.25,85,,,percent of total billed charges,85% of total billed charges,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.7,130,,,fee schedule,Pays 130% Medicare OPPS,17.61,120.37,,,fee schedule,120.37% of custom fee schedule,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.67,102,,,fee schedule,Pays 102% Medicare OPPS,436.5,90,,,percent of total billed charges,90% of total billed charges,18.31,125.18,,,fee schedule,125.18% of custom fee schedule,333.2,68.7,,,percent of total billed charges,68.7% of total billed charges,388,80,,,percent of total billed charges,80 percent of total billed charges,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.95,90,,,fee schedule,Pays 90% Medicare OPPS,281.3,58,,,percent of total billed charges,58% of total billed charges,17.61,120.37,,,fee schedule,120.37% of custom fee schedule,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.7,130,,,fee schedule,Pays 130% Medicare OPPS,412.25,85,,,percent of total billed charges,85% of total billed charges,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.95,436.5,
3RD WEST NILE IGM VIRUS (CSF),3000548,CDM,302,RC,86789,HCPCS,Outpatient,,,485,388,,412.25,85,,,percent of total billed charges,85% of total billed charges,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.7,130,,,fee schedule,Pays 130% Medicare OPPS,17.61,120.37,,,fee schedule,120.37% of custom fee schedule,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.67,102,,,fee schedule,Pays 102% Medicare OPPS,436.5,90,,,percent of total billed charges,90% of total billed charges,18.31,125.18,,,fee schedule,125.18% of custom fee schedule,333.2,68.7,,,percent of total billed charges,68.7% of total billed charges,388,80,,,percent of total billed charges,80 percent of total billed charges,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.95,90,,,fee schedule,Pays 90% Medicare OPPS,281.3,58,,,percent of total billed charges,58% of total billed charges,17.61,120.37,,,fee schedule,120.37% of custom fee schedule,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.7,130,,,fee schedule,Pays 130% Medicare OPPS,412.25,85,,,percent of total billed charges,85% of total billed charges,14.39,100,,,fee schedule,Pays 100% Medicare OPPS,12.95,436.5,
Kidney function panel test,3080069,CDM,301,RC,80069,HCPCS,Outpatient,,,485,388,,412.25,85,,,percent of total billed charges,85% of total billed charges,8.68,100,,,fee schedule,Pays 100% Medicare OPPS,8.68,100,,,fee schedule,Pays 100% Medicare OPPS,8.68,100,,,fee schedule,Pays 100% Medicare OPPS,11.28,130,,,fee schedule,Pays 130% Medicare OPPS,13.14,120.37,,,fee schedule,120.37% of custom fee schedule,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.85,102,,,fee schedule,Pays 102% Medicare OPPS,436.5,90,,,percent of total billed charges,90% of total billed charges,13.67,125.18,,,fee schedule,125.18% of custom fee schedule,333.2,68.7,,,percent of total billed charges,68.7% of total billed charges,388,80,,,percent of total billed charges,80 percent of total billed charges,8.68,100,,,fee schedule,Pays 100% Medicare OPPS,7.81,90,,,fee schedule,Pays 90% Medicare OPPS,281.3,58,,,percent of total billed charges,58% of total billed charges,13.14,120.37,,,fee schedule,120.37% of custom fee schedule,8.68,100,,,fee schedule,Pays 100% Medicare OPPS,11.28,130,,,fee schedule,Pays 130% Medicare OPPS,412.25,85,,,percent of total billed charges,85% of total billed charges,8.68,100,,,fee schedule,Pays 100% Medicare OPPS,7.81,436.5,
LASA (SIALIC ACID),3084275,CDM,301,RC,84275,HCPCS,Outpatient,,,485,388,,412.25,85,,,percent of total billed charges,85% of total billed charges,13.44,100,,,fee schedule,Pays 100% Medicare OPPS,13.44,100,,,fee schedule,Pays 100% Medicare OPPS,13.44,100,,,fee schedule,Pays 100% Medicare OPPS,17.47,130,,,fee schedule,Pays 130% Medicare OPPS,20.33,120.37,,,fee schedule,120.37% of custom fee schedule,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.7,102,,,fee schedule,Pays 102% Medicare OPPS,436.5,90,,,percent of total billed charges,90% of total billed charges,21.14,125.18,,,fee schedule,125.18% of custom fee schedule,333.2,68.7,,,percent of total billed charges,68.7% of total billed charges,388,80,,,percent of total billed charges,80 percent of total billed charges,13.44,100,,,fee schedule,Pays 100% Medicare OPPS,12.09,90,,,fee schedule,Pays 90% Medicare OPPS,281.3,58,,,percent of total billed charges,58% of total billed charges,20.33,120.37,,,fee schedule,120.37% of custom fee schedule,13.44,100,,,fee schedule,Pays 100% Medicare OPPS,17.47,130,,,fee schedule,Pays 130% Medicare OPPS,412.25,85,,,percent of total billed charges,85% of total billed charges,13.44,100,,,fee schedule,Pays 100% Medicare OPPS,12.09,436.5,
3RD ANTI GBM (GLOMERULAR B),3086318,CDM,302,RC,83520,HCPCS,Outpatient,,,485,388,,412.25,85,,,percent of total billed charges,85% of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,130,,,fee schedule,Pays 130% Medicare OPPS,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.61,102,,,fee schedule,Pays 102% Medicare OPPS,436.5,90,,,percent of total billed charges,90% of total billed charges,20.38,125.18,,,fee schedule,125.18% of custom fee schedule,333.2,68.7,,,percent of total billed charges,68.7% of total billed charges,388,80,,,percent of total billed charges,80 percent of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,15.54,90,,,fee schedule,Pays 90% Medicare OPPS,281.3,58,,,percent of total billed charges,58% of total billed charges,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,130,,,fee schedule,Pays 130% Medicare OPPS,412.25,85,,,percent of total billed charges,85% of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,15.54,436.5,
"ABSOLUTE CD4,CD8&CD19",3086360,CDM,302,RC,86360,HCPCS,Outpatient,,,485,388,,412.25,85,,,percent of total billed charges,85% of total billed charges,46.98,100,,,fee schedule,Pays 100% Medicare OPPS,46.98,100,,,fee schedule,Pays 100% Medicare OPPS,46.98,100,,,fee schedule,Pays 100% Medicare OPPS,61.07,130,,,fee schedule,Pays 130% Medicare OPPS,71.13,120.37,,,fee schedule,120.37% of custom fee schedule,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,47.91,102,,,fee schedule,Pays 102% Medicare OPPS,436.5,90,,,percent of total billed charges,90% of total billed charges,73.97,125.18,,,fee schedule,125.18% of custom fee schedule,333.2,68.7,,,percent of total billed charges,68.7% of total billed charges,388,80,,,percent of total billed charges,80 percent of total billed charges,46.98,100,,,fee schedule,Pays 100% Medicare OPPS,42.28,90,,,fee schedule,Pays 90% Medicare OPPS,281.3,58,,,percent of total billed charges,58% of total billed charges,71.13,120.37,,,fee schedule,120.37% of custom fee schedule,46.98,100,,,fee schedule,Pays 100% Medicare OPPS,61.07,130,,,fee schedule,Pays 130% Medicare OPPS,412.25,85,,,percent of total billed charges,85% of total billed charges,46.98,100,,,fee schedule,Pays 100% Medicare OPPS,42.28,436.5,
CD4 COUNT,3086361,CDM,311,RC,86361,HCPCS,Outpatient,,,485,388,,412.25,85,,,percent of total billed charges,85% of total billed charges,26.78,100,,,fee schedule,Pays 100% Medicare OPPS,26.78,100,,,fee schedule,Pays 100% Medicare OPPS,26.78,100,,,fee schedule,Pays 100% Medicare OPPS,34.81,130,,,fee schedule,Pays 130% Medicare OPPS,39.51,120.37,,,fee schedule,120.37% of custom fee schedule,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,27.31,102,,,fee schedule,Pays 102% Medicare OPPS,436.5,90,,,percent of total billed charges,90% of total billed charges,41.08,125.18,,,fee schedule,125.18% of custom fee schedule,333.2,68.7,,,percent of total billed charges,68.7% of total billed charges,388,80,,,percent of total billed charges,80 percent of total billed charges,26.78,100,,,fee schedule,Pays 100% Medicare OPPS,24.1,90,,,fee schedule,Pays 90% Medicare OPPS,281.3,58,,,percent of total billed charges,58% of total billed charges,39.51,120.37,,,fee schedule,120.37% of custom fee schedule,26.78,100,,,fee schedule,Pays 100% Medicare OPPS,34.81,130,,,fee schedule,Pays 130% Medicare OPPS,412.25,85,,,percent of total billed charges,85% of total billed charges,26.78,100,,,fee schedule,Pays 100% Medicare OPPS,24.1,436.5,
"3RD HERPES SIMPLEX VIRUS,QUAN",3087530,CDM,300,RC,87530,HCPCS,Outpatient,,,485,388,,412.25,85,,,percent of total billed charges,85% of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,130,,,fee schedule,Pays 130% Medicare OPPS,98.79,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,43.69,102,,,fee schedule,Pays 102% Medicare OPPS,436.5,90,,,percent of total billed charges,90% of total billed charges,169.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,333.2,68.7,,,percent of total billed charges,68.7% of total billed charges,388,80,,,percent of total billed charges,80 percent of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,38.55,90,,,fee schedule,Pays 90% Medicare OPPS,281.3,58,,,percent of total billed charges,58% of total billed charges,98.79,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,130,,,fee schedule,Pays 130% Medicare OPPS,412.25,85,,,percent of total billed charges,85% of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,38.55,436.5,
XR CHOLIGRAFIN IVC,4000032,CDM,255,RC,,,Outpatient,,,485,388,,412.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,98.79,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,436.5,90,,,percent of total billed charges,90% of total billed charges,169.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,333.2,68.7,,,percent of total billed charges,68.7% of total billed charges,388,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,281.3,58,,,percent of total billed charges,58% of total billed charges,98.79,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,98.79,436.5,
ARTHROSCOPIC PACK,7901226,CDM,270,RC,,,Outpatient,,,485,388,,412.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,98.79,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,274.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,436.5,90,,,percent of total billed charges,90% of total billed charges,169.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,333.2,68.7,,,percent of total billed charges,68.7% of total billed charges,388,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,281.3,58,,,percent of total billed charges,58% of total billed charges,98.79,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,412.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,98.79,436.5,
"Incision and Drainage Procedures on the Skin, Subcutaneous and Accessory Structures",1510040,CDM,761,RC,10040,HCPCS,Outpatient,,,490,392,,416.5,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,99.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,276.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,276.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,276.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,276.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,164.54,102,,,fee schedule,Pays 102% Medicare OPPS,441,90,,,percent of total billed charges,90% of total billed charges,171.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,336.63,68.7,,,percent of total billed charges,68.7% of total billed charges,392,80,,,percent of total billed charges,80 percent of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,145.18,90,,,fee schedule,Pays 90% Medicare OPPS,284.2,58,,,percent of total billed charges,58% of total billed charges,99.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.83,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,416.5,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,99.81,441,
Incision and drainage of abscess; simple or single and complex or multiple,1510060,CDM,450,RC,10060,HCPCS,Outpatient,,,490,392,,416.5,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,99.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,276.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,276.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,276.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,276.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,164.53,102,,,fee schedule,Pays 102% Medicare OPPS,441,90,,,percent of total billed charges,90% of total billed charges,171.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,336.63,68.7,,,percent of total billed charges,68.7% of total billed charges,392,80,,,percent of total billed charges,80 percent of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,145.18,90,,,fee schedule,Pays 90% Medicare OPPS,284.2,58,,,percent of total billed charges,58% of total billed charges,99.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.83,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,416.5,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,99.81,441,
BURN MED FACE/1 EXTREM,2016025,CDM,450,RC,16025,HCPCS,Outpatient,,,490,392,,416.5,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,99.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,276.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,276.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,276.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,276.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,164.53,102,,,fee schedule,Pays 102% Medicare OPPS,441,90,,,percent of total billed charges,90% of total billed charges,171.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,336.63,68.7,,,percent of total billed charges,68.7% of total billed charges,392,80,,,percent of total billed charges,80 percent of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,145.18,90,,,fee schedule,Pays 90% Medicare OPPS,284.2,58,,,percent of total billed charges,58% of total billed charges,99.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.83,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,416.5,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,99.81,441,
XR CHEST AND OBLIQUES,4071022,CDM,324,RC,71022,HCPCS,Outpatient,,,490,392,,416.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,99.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,276.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,276.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,276.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,275.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,441,90,,,percent of total billed charges,90% of total billed charges,171.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,336.63,68.7,,,percent of total billed charges,68.7% of total billed charges,392,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,284.2,58,,,percent of total billed charges,58% of total billed charges,99.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,416.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,99.81,441,
ENDO RELOADS 35 MM,7950262,CDM,270,RC,,,Outpatient,,,490,392,,416.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,99.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,276.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,276.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,276.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,276.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,441,90,,,percent of total billed charges,90% of total billed charges,171.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,336.63,68.7,,,percent of total billed charges,68.7% of total billed charges,392,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,284.2,58,,,percent of total billed charges,58% of total billed charges,99.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,416.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,99.81,441,
EXCISION SKIN LESION/BIOPSY OF SKIN,1011100,CDM,490,RC,,,Outpatient,,,500,400,,425,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,101.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,450,90,,,percent of total billed charges,90% of total billed charges,175,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,343.5,68.7,,,percent of total billed charges,68.7% of total billed charges,400,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,290,58,,,percent of total billed charges,58% of total billed charges,101.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,425,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,101.85,450,
"Removal of skin tags, multiple fibrocutaneous tags, any area",1011200,CDM,490,RC,11200,HCPCS,Outpatient,,,500,400,,425,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,101.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,164.54,102,,,fee schedule,Pays 102% Medicare OPPS,450,90,,,percent of total billed charges,90% of total billed charges,175,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,343.5,68.7,,,percent of total billed charges,68.7% of total billed charges,400,80,,,percent of total billed charges,80 percent of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,145.18,90,,,fee schedule,Pays 90% Medicare OPPS,290,58,,,percent of total billed charges,58% of total billed charges,101.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.83,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,425,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,101.85,986.63,
EXCISION SKIN LESION,1011422,CDM,490,RC,,,Outpatient,,,500,400,,425,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,101.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,450,90,,,percent of total billed charges,90% of total billed charges,175,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,343.5,68.7,,,percent of total billed charges,68.7% of total billed charges,400,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,290,58,,,percent of total billed charges,58% of total billed charges,101.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,425,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,101.85,450,
Destruction of 1-14 common or plantar warts,1517110,CDM,360,RC,17110,HCPCS,Outpatient,,,500,400,,425,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,101.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,164.54,102,,,fee schedule,Pays 102% Medicare OPPS,450,90,,,percent of total billed charges,90% of total billed charges,175,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,343.5,68.7,,,percent of total billed charges,68.7% of total billed charges,400,80,,,percent of total billed charges,80 percent of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,145.18,90,,,fee schedule,Pays 90% Medicare OPPS,290,58,,,percent of total billed charges,58% of total billed charges,101.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.83,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,425,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,101.85,986.63,
"Puncture aspiration of abscess, hematoma, bulla, or cyst",2010160,CDM,450,RC,10160,HCPCS,Outpatient,,,500,400,,425,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,101.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,316.7,102,,,fee schedule,Pays 102% Medicare OPPS,450,90,,,percent of total billed charges,90% of total billed charges,175,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,343.5,68.7,,,percent of total billed charges,68.7% of total billed charges,400,80,,,percent of total billed charges,80 percent of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,279.44,90,,,fee schedule,Pays 90% Medicare OPPS,290,58,,,percent of total billed charges,58% of total billed charges,101.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,328.14,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,425,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,101.85,450,
NIACIN LEVEL,3000223,CDM,301,RC,84591,HCPCS,Outpatient,,,500,400,,425,85,,,percent of total billed charges,85% of total billed charges,17.05,100,,,fee schedule,Pays 100% Medicare OPPS,17.05,100,,,fee schedule,Pays 100% Medicare OPPS,17.05,100,,,fee schedule,Pays 100% Medicare OPPS,22.17,130,,,fee schedule,Pays 130% Medicare OPPS,17.55,120.37,,,fee schedule,120.37% of custom fee schedule,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.4,102,,,fee schedule,Pays 102% Medicare OPPS,450,90,,,percent of total billed charges,90% of total billed charges,18.25,125.18,,,fee schedule,125.18% of custom fee schedule,343.5,68.7,,,percent of total billed charges,68.7% of total billed charges,400,80,,,percent of total billed charges,80 percent of total billed charges,17.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.35,90,,,fee schedule,Pays 90% Medicare OPPS,290,58,,,percent of total billed charges,58% of total billed charges,17.55,120.37,,,fee schedule,120.37% of custom fee schedule,17.05,100,,,fee schedule,Pays 100% Medicare OPPS,22.17,130,,,fee schedule,Pays 130% Medicare OPPS,425,85,,,percent of total billed charges,85% of total billed charges,17.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.35,450,
Blood test to monitor vitamin D levels,3082306,CDM,301,RC,82306,HCPCS,Outpatient,,,500,400,,425,85,,,percent of total billed charges,85% of total billed charges,29.6,100,,,fee schedule,Pays 100% Medicare OPPS,29.6,100,,,fee schedule,Pays 100% Medicare OPPS,29.6,100,,,fee schedule,Pays 100% Medicare OPPS,38.48,130,,,fee schedule,Pays 130% Medicare OPPS,44.8,120.37,,,fee schedule,120.37% of custom fee schedule,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,30.19,102,,,fee schedule,Pays 102% Medicare OPPS,450,90,,,percent of total billed charges,90% of total billed charges,46.59,125.18,,,fee schedule,125.18% of custom fee schedule,343.5,68.7,,,percent of total billed charges,68.7% of total billed charges,400,80,,,percent of total billed charges,80 percent of total billed charges,29.6,100,,,fee schedule,Pays 100% Medicare OPPS,26.64,90,,,fee schedule,Pays 90% Medicare OPPS,290,58,,,percent of total billed charges,58% of total billed charges,44.8,120.37,,,fee schedule,120.37% of custom fee schedule,29.6,100,,,fee schedule,Pays 100% Medicare OPPS,38.48,130,,,fee schedule,Pays 130% Medicare OPPS,425,85,,,percent of total billed charges,85% of total billed charges,29.6,100,,,fee schedule,Pays 100% Medicare OPPS,26.64,450,
3RD HISTAMINE LEVEL,3083088,CDM,301,RC,83088,HCPCS,Outpatient,,,500,400,,425,85,,,percent of total billed charges,85% of total billed charges,29.53,100,,,fee schedule,Pays 100% Medicare OPPS,29.53,100,,,fee schedule,Pays 100% Medicare OPPS,29.53,100,,,fee schedule,Pays 100% Medicare OPPS,38.38,130,,,fee schedule,Pays 130% Medicare OPPS,44.69,120.37,,,fee schedule,120.37% of custom fee schedule,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,30.12,102,,,fee schedule,Pays 102% Medicare OPPS,450,90,,,percent of total billed charges,90% of total billed charges,46.48,125.18,,,fee schedule,125.18% of custom fee schedule,343.5,68.7,,,percent of total billed charges,68.7% of total billed charges,400,80,,,percent of total billed charges,80 percent of total billed charges,29.53,100,,,fee schedule,Pays 100% Medicare OPPS,26.57,90,,,fee schedule,Pays 90% Medicare OPPS,290,58,,,percent of total billed charges,58% of total billed charges,44.69,120.37,,,fee schedule,120.37% of custom fee schedule,29.53,100,,,fee schedule,Pays 100% Medicare OPPS,38.38,130,,,fee schedule,Pays 130% Medicare OPPS,425,85,,,percent of total billed charges,85% of total billed charges,29.53,100,,,fee schedule,Pays 100% Medicare OPPS,26.57,450,
"MOLECULAR DIAG, MUT SCAN",3083903,CDM,301,RC,83903,HCPCS,Outpatient,,,500,400,,425,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,101.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,450,90,,,percent of total billed charges,90% of total billed charges,175,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,343.5,68.7,,,percent of total billed charges,68.7% of total billed charges,400,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,290,58,,,percent of total billed charges,58% of total billed charges,101.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,425,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,101.85,450,
XR STERNO/CLAV JTS 3 VIEWS,4071130,CDM,320,RC,71130,HCPCS,Outpatient,,,500,400,,425,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,101.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,281,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,450,90,,,percent of total billed charges,90% of total billed charges,175,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,343.5,68.7,,,percent of total billed charges,68.7% of total billed charges,400,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,290,58,,,percent of total billed charges,58% of total billed charges,101.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,425,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,450,
PT WOUND CARE SEL GR 20SQCM (PER SESSION,5097598,CDM,420,RC,97598,HCPCS,Outpatient,,,500,400,,425,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,101.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,450,90,,,percent of total billed charges,90% of total billed charges,175,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,343.5,68.7,,,percent of total billed charges,68.7% of total billed charges,400,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,290,58,,,percent of total billed charges,58% of total billed charges,101.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,425,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,101.85,450,
OT WOUND CARE SEL <20SQCM (PER SESSION),5197598,CDM,430,RC,97598,HCPCS,Outpatient,,,500,400,,425,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,101.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,450,90,,,percent of total billed charges,90% of total billed charges,175,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,343.5,68.7,,,percent of total billed charges,68.7% of total billed charges,400,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,290,58,,,percent of total billed charges,58% of total billed charges,101.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,425,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,101.85,450,
PNEUMOTHORAX KIT,7905663,CDM,270,RC,,,Outpatient,,,500,400,,425,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,101.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,282.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,450,90,,,percent of total billed charges,90% of total billed charges,175,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,343.5,68.7,,,percent of total billed charges,68.7% of total billed charges,400,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,290,58,,,percent of total billed charges,58% of total billed charges,101.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,425,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,101.85,450,
PULMICORT FLEXHALER 180MCG MDI,2600119,CDM,637,RC,,,Outpatient,,,505,404,,429.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,102.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,285.33,56.5,,,percent of total billed charges,56.5 percent of total billed charges,285.33,56.5,,,percent of total billed charges,56.5 percent of total billed charges,285.33,56.5,,,percent of total billed charges,56.5 percent of total billed charges,285.33,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,454.5,90,,,percent of total billed charges,90% of total billed charges,176.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,346.94,68.7,,,percent of total billed charges,68.7% of total billed charges,404,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,292.9,58,,,percent of total billed charges,58% of total billed charges,102.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,429.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,102.87,454.5,
3RD RISTOCETIN CO FACTOR ASSA,3000264,CDM,305,RC,85245,HCPCS,Outpatient,,,510,408,,433.5,85,,,percent of total billed charges,85% of total billed charges,22.94,100,,,fee schedule,Pays 100% Medicare OPPS,22.94,100,,,fee schedule,Pays 100% Medicare OPPS,22.94,100,,,fee schedule,Pays 100% Medicare OPPS,29.82,130,,,fee schedule,Pays 130% Medicare OPPS,34.73,120.37,,,fee schedule,120.37% of custom fee schedule,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,23.39,102,,,fee schedule,Pays 102% Medicare OPPS,459,90,,,percent of total billed charges,90% of total billed charges,36.11,125.18,,,fee schedule,125.18% of custom fee schedule,350.37,68.7,,,percent of total billed charges,68.7% of total billed charges,408,80,,,percent of total billed charges,80 percent of total billed charges,22.94,100,,,fee schedule,Pays 100% Medicare OPPS,20.64,90,,,fee schedule,Pays 90% Medicare OPPS,295.8,58,,,percent of total billed charges,58% of total billed charges,34.73,120.37,,,fee schedule,120.37% of custom fee schedule,22.94,100,,,fee schedule,Pays 100% Medicare OPPS,29.82,130,,,fee schedule,Pays 130% Medicare OPPS,433.5,85,,,percent of total billed charges,85% of total billed charges,22.94,100,,,fee schedule,Pays 100% Medicare OPPS,20.64,459,
BB RHO(D) INJECTION,3000276,CDM,636,RC,J2790,HCPCS,Both,,,510,408,,433.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,96.79,120.37,,,fee schedule,120.37% of custom fee schedule,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,459,90,,,percent of total billed charges,90% of total billed charges,100.66,125.18,,,fee schedule,125.18% of custom fee schedule,350.37,68.7,,,percent of total billed charges,68.7% of total billed charges,408,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,295.8,58,,,percent of total billed charges,58% of total billed charges,96.79,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,433.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,459,
"HOMOCYSTEINE, SERUM",3083090,CDM,301,RC,83090,HCPCS,Outpatient,,,510,408,,433.5,85,,,percent of total billed charges,85% of total billed charges,17.92,100,,,fee schedule,Pays 100% Medicare OPPS,17.92,100,,,fee schedule,Pays 100% Medicare OPPS,17.92,100,,,fee schedule,Pays 100% Medicare OPPS,23.29,130,,,fee schedule,Pays 130% Medicare OPPS,25.53,120.37,,,fee schedule,120.37% of custom fee schedule,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.27,102,,,fee schedule,Pays 102% Medicare OPPS,459,90,,,percent of total billed charges,90% of total billed charges,26.55,125.18,,,fee schedule,125.18% of custom fee schedule,350.37,68.7,,,percent of total billed charges,68.7% of total billed charges,408,80,,,percent of total billed charges,80 percent of total billed charges,17.92,100,,,fee schedule,Pays 100% Medicare OPPS,16.12,90,,,fee schedule,Pays 90% Medicare OPPS,295.8,58,,,percent of total billed charges,58% of total billed charges,25.53,120.37,,,fee schedule,120.37% of custom fee schedule,17.92,100,,,fee schedule,Pays 100% Medicare OPPS,23.29,130,,,fee schedule,Pays 130% Medicare OPPS,433.5,85,,,percent of total billed charges,85% of total billed charges,17.92,100,,,fee schedule,Pays 100% Medicare OPPS,16.12,459,
"MYELIN BASIC PROTEIN,CSF",3083873,CDM,301,RC,83873,HCPCS,Outpatient,,,510,408,,433.5,85,,,percent of total billed charges,85% of total billed charges,17.2,100,,,fee schedule,Pays 100% Medicare OPPS,17.2,100,,,fee schedule,Pays 100% Medicare OPPS,17.2,100,,,fee schedule,Pays 100% Medicare OPPS,22.36,130,,,fee schedule,Pays 130% Medicare OPPS,26.05,120.37,,,fee schedule,120.37% of custom fee schedule,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.54,102,,,fee schedule,Pays 102% Medicare OPPS,459,90,,,percent of total billed charges,90% of total billed charges,27.09,125.18,,,fee schedule,125.18% of custom fee schedule,350.37,68.7,,,percent of total billed charges,68.7% of total billed charges,408,80,,,percent of total billed charges,80 percent of total billed charges,17.2,100,,,fee schedule,Pays 100% Medicare OPPS,15.48,90,,,fee schedule,Pays 90% Medicare OPPS,295.8,58,,,percent of total billed charges,58% of total billed charges,26.05,120.37,,,fee schedule,120.37% of custom fee schedule,17.2,100,,,fee schedule,Pays 100% Medicare OPPS,22.36,130,,,fee schedule,Pays 130% Medicare OPPS,433.5,85,,,percent of total billed charges,85% of total billed charges,17.2,100,,,fee schedule,Pays 100% Medicare OPPS,15.48,459,
LEGIONELLA ANTIBODIES IgG,3086713,CDM,302,RC,86713,HCPCS,Outpatient,,,510,408,,433.5,85,,,percent of total billed charges,85% of total billed charges,15.3,100,,,fee schedule,Pays 100% Medicare OPPS,15.3,100,,,fee schedule,Pays 100% Medicare OPPS,15.3,100,,,fee schedule,Pays 100% Medicare OPPS,19.89,130,,,fee schedule,Pays 130% Medicare OPPS,23.17,120.37,,,fee schedule,120.37% of custom fee schedule,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.6,102,,,fee schedule,Pays 102% Medicare OPPS,459,90,,,percent of total billed charges,90% of total billed charges,24.1,125.18,,,fee schedule,125.18% of custom fee schedule,350.37,68.7,,,percent of total billed charges,68.7% of total billed charges,408,80,,,percent of total billed charges,80 percent of total billed charges,15.3,100,,,fee schedule,Pays 100% Medicare OPPS,13.77,90,,,fee schedule,Pays 90% Medicare OPPS,295.8,58,,,percent of total billed charges,58% of total billed charges,23.17,120.37,,,fee schedule,120.37% of custom fee schedule,15.3,100,,,fee schedule,Pays 100% Medicare OPPS,19.89,130,,,fee schedule,Pays 130% Medicare OPPS,433.5,85,,,percent of total billed charges,85% of total billed charges,15.3,100,,,fee schedule,Pays 100% Medicare OPPS,13.77,459,
BB PLT PALL FILTER,3100701,CDM,270,RC,,,Outpatient,,,510,408,,433.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,103.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,459,90,,,percent of total billed charges,90% of total billed charges,178.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,350.37,68.7,,,percent of total billed charges,68.7% of total billed charges,408,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,295.8,58,,,percent of total billed charges,58% of total billed charges,103.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,433.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,103.89,459,
Radiologic examination of the knee with 3 views,4073562,CDM,320,RC,73562,HCPCS,Outpatient,,,510,408,,433.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,103.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,286.62,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,459,90,,,percent of total billed charges,90% of total billed charges,178.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,350.37,68.7,,,percent of total billed charges,68.7% of total billed charges,408,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,295.8,58,,,percent of total billed charges,58% of total billed charges,103.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,433.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,459,
Radiologic examination of the knee with 3 views,4083562,CDM,320,RC,73562,HCPCS,Outpatient,,,510,408,,433.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,103.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,286.62,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,459,90,,,percent of total billed charges,90% of total billed charges,178.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,350.37,68.7,,,percent of total billed charges,68.7% of total billed charges,408,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,295.8,58,,,percent of total billed charges,58% of total billed charges,103.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,433.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,459,
LMA DISPO,7905054,CDM,270,RC,,,Outpatient,,,510,408,,433.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,103.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,288.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,459,90,,,percent of total billed charges,90% of total billed charges,178.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,350.37,68.7,,,percent of total billed charges,68.7% of total billed charges,408,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,295.8,58,,,percent of total billed charges,58% of total billed charges,103.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,433.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,103.89,459,
NEEDLE EZ-IO W/STABILIZER KIT,7905945,CDM,272,RC,,,Outpatient,,,518.25,414.6,,440.51,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,105.57,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,292.81,56.5,,,percent of total billed charges,56.5 percent of total billed charges,292.81,56.5,,,percent of total billed charges,56.5 percent of total billed charges,292.81,56.5,,,percent of total billed charges,56.5 percent of total billed charges,292.81,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,466.43,90,,,percent of total billed charges,90% of total billed charges,181.39,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,356.04,68.7,,,percent of total billed charges,68.7% of total billed charges,414.6,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,300.59,58,,,percent of total billed charges,58% of total billed charges,105.57,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,440.51,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,105.57,466.43,
RABIES VACCINE INJECTION : 1ML,2601046,CDM,636,RC,90675,HCPCS,Both,,,520,416,,442,85,,,percent of total billed charges,85% of total billed charges,348.53,100,,,fee schedule,Pays 100% Medicare OPPS,348.53,100,,,fee schedule,Pays 100% Medicare OPPS,348.53,100,,,fee schedule,Pays 100% Medicare OPPS,427.11,130,,,fee schedule,Pays 130% Medicare OPPS,419.53,120.37,,,fee schedule,120.37% of custom fee schedule,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,355.5,102,,,fee schedule,Pays 102% Medicare OPPS,468,90,,,percent of total billed charges,90% of total billed charges,436.29,125.18,,,fee schedule,125.18% of custom fee schedule,357.24,68.7,,,percent of total billed charges,68.7% of total billed charges,416,80,,,percent of total billed charges,80 percent of total billed charges,348.53,100,,,fee schedule,Pays 100% Medicare OPPS,313.67,90,,,fee schedule,Pays 90% Medicare OPPS,301.6,58,,,percent of total billed charges,58% of total billed charges,419.53,120.37,,,fee schedule,120.37% of custom fee schedule,328.55,100,,,fee schedule,Pays 100% Medicare OPPS,427.11,130,,,fee schedule,Pays 130% Medicare OPPS,442,85,,,percent of total billed charges,85% of total billed charges,348.53,100,,,fee schedule,Pays 100% Medicare OPPS,0.01,468,
PROINSULIN LEVEL,3084206,CDM,301,RC,84206,HCPCS,Outpatient,,,520,416,,442,85,,,percent of total billed charges,85% of total billed charges,26.69,100,,,fee schedule,Pays 100% Medicare OPPS,26.69,100,,,fee schedule,Pays 100% Medicare OPPS,26.69,100,,,fee schedule,Pays 100% Medicare OPPS,34.69,130,,,fee schedule,Pays 130% Medicare OPPS,26.96,120.37,,,fee schedule,120.37% of custom fee schedule,293.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,293.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,293.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,293.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,27.22,102,,,fee schedule,Pays 102% Medicare OPPS,468,90,,,percent of total billed charges,90% of total billed charges,28.04,125.18,,,fee schedule,125.18% of custom fee schedule,357.24,68.7,,,percent of total billed charges,68.7% of total billed charges,416,80,,,percent of total billed charges,80 percent of total billed charges,26.69,100,,,fee schedule,Pays 100% Medicare OPPS,24.02,90,,,fee schedule,Pays 90% Medicare OPPS,301.6,58,,,percent of total billed charges,58% of total billed charges,26.96,120.37,,,fee schedule,120.37% of custom fee schedule,26.69,100,,,fee schedule,Pays 100% Medicare OPPS,34.69,130,,,fee schedule,Pays 130% Medicare OPPS,442,85,,,percent of total billed charges,85% of total billed charges,26.69,100,,,fee schedule,Pays 100% Medicare OPPS,24.02,468,
XR ABDOMEN FLATUPRIGHT,4074020,CDM,320,RC,74018,HCPCS,Outpatient,,,520,416,,442,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,105.92,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,293.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,293.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,293.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,292.24,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,468,90,,,percent of total billed charges,90% of total billed charges,182,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,357.24,68.7,,,percent of total billed charges,68.7% of total billed charges,416,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,301.6,58,,,percent of total billed charges,58% of total billed charges,105.92,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,442,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,468,
US ADDITIONAL CYST ASPIRATION,4619001,CDM,402,RC,19001,HCPCS,Outpatient,,,520,416,,442,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,105.92,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,293.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,293.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,293.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,292.24,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,468,90,,,percent of total billed charges,90% of total billed charges,182,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,357.24,68.7,,,percent of total billed charges,68.7% of total billed charges,416,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,301.6,58,,,percent of total billed charges,58% of total billed charges,105.92,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,442,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,105.92,468,
FLUTTER DEVICE SCA-910,7915710,CDM,270,RC,,,Outpatient,,,520,416,,442,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,105.92,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,293.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,293.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,293.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,293.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,468,90,,,percent of total billed charges,90% of total billed charges,182,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,357.24,68.7,,,percent of total billed charges,68.7% of total billed charges,416,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,301.6,58,,,percent of total billed charges,58% of total billed charges,105.92,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,442,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,105.92,468,
SURGICLIP II,7950140,CDM,270,RC,,,Outpatient,,,520,416,,442,85,,,percent of total billed charges,85% of total billed charges,130,100,,,fee schedule,Pays 100% Medicare OPPS,130,100,,,fee schedule,Pays 100% Medicare OPPS,130,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,105.92,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,293.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,293.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,293.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,293.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,468,90,,,percent of total billed charges,90% of total billed charges,182,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,357.24,68.7,,,percent of total billed charges,68.7% of total billed charges,416,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,468,90,,,fee schedule,Pays 90% Medicare OPPS,301.6,58,,,percent of total billed charges,58% of total billed charges,105.92,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,442,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,105.92,468,
OBSERVATION 1ST HOUR,100001,CDM,762,RC,G0378,HCPCS,Outpatient,,,525,420,,446.25,85,,,percent of total billed charges,85% of total billed charges,131.25,100,,,fee schedule,Pays 100% Medicare OPPS,131.25,100,,,fee schedule,Pays 100% Medicare OPPS,131.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,106.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,472.5,90,,,percent of total billed charges,90% of total billed charges,183.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,360.68,68.7,,,percent of total billed charges,68.7% of total billed charges,420,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,472.5,90,,,fee schedule,Pays 90% Medicare OPPS,304.5,58,,,percent of total billed charges,58% of total billed charges,106.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,446.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,106.94,472.5,
OBSERVATION (DIRECT ADM),100003,CDM,762,RC,99219,HCPCS,Outpatient,,,525,420,,446.25,85,,,percent of total billed charges,85% of total billed charges,131.25,100,,,fee schedule,Pays 100% Medicare OPPS,131.25,100,,,fee schedule,Pays 100% Medicare OPPS,131.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,106.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,472.5,90,,,percent of total billed charges,90% of total billed charges,183.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,360.68,68.7,,,percent of total billed charges,68.7% of total billed charges,420,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,472.5,90,,,fee schedule,Pays 90% Medicare OPPS,304.5,58,,,percent of total billed charges,58% of total billed charges,106.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,446.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,106.94,472.5,
I & D SUPERFICIAL ABSCESS,1046045,CDM,762,RC,,,Outpatient,,,525,420,,446.25,85,,,percent of total billed charges,85% of total billed charges,131.25,100,,,fee schedule,Pays 100% Medicare OPPS,131.25,100,,,fee schedule,Pays 100% Medicare OPPS,131.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,106.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,472.5,90,,,percent of total billed charges,90% of total billed charges,183.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,360.68,68.7,,,percent of total billed charges,68.7% of total billed charges,420,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,472.5,90,,,fee schedule,Pays 90% Medicare OPPS,304.5,58,,,percent of total billed charges,58% of total billed charges,106.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,446.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,106.94,472.5,
BURN LARGE >1 EXTREMETY,2016030,CDM,450,RC,16030,HCPCS,Outpatient,,,525,420,,446.25,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,106.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,316.7,102,,,fee schedule,Pays 102% Medicare OPPS,472.5,90,,,percent of total billed charges,90% of total billed charges,183.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,360.68,68.7,,,percent of total billed charges,68.7% of total billed charges,420,80,,,percent of total billed charges,80 percent of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,279.44,90,,,fee schedule,Pays 90% Medicare OPPS,304.5,58,,,percent of total billed charges,58% of total billed charges,106.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,328.14,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,446.25,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,106.94,472.5,
RIFAMPIN 600MG VIAL,2600118,CDM,250,RC,,,Outpatient,,,525,420,,446.25,85,,,percent of total billed charges,85% of total billed charges,131.25,100,,,fee schedule,Pays 100% Medicare OPPS,131.25,100,,,fee schedule,Pays 100% Medicare OPPS,131.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,106.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,472.5,90,,,percent of total billed charges,90% of total billed charges,183.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,360.68,68.7,,,percent of total billed charges,68.7% of total billed charges,420,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,472.5,90,,,fee schedule,Pays 90% Medicare OPPS,304.5,58,,,percent of total billed charges,58% of total billed charges,106.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,446.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,106.94,472.5,
ASTELIN NASAL 137MCG/SPRAY (30ML),2600123,CDM,637,RC,,,Outpatient,,,525,420,,446.25,85,,,percent of total billed charges,85% of total billed charges,131.25,100,,,fee schedule,Pays 100% Medicare OPPS,131.25,100,,,fee schedule,Pays 100% Medicare OPPS,131.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,106.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,472.5,90,,,percent of total billed charges,90% of total billed charges,183.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,360.68,68.7,,,percent of total billed charges,68.7% of total billed charges,420,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,472.5,90,,,fee schedule,Pays 90% Medicare OPPS,304.5,58,,,percent of total billed charges,58% of total billed charges,106.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,446.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,106.94,472.5,
"ALDOSTERONE, URINE",3000002,CDM,301,RC,82088,HCPCS,Outpatient,,,525,420,,446.25,85,,,percent of total billed charges,85% of total billed charges,40.75,100,,,fee schedule,Pays 100% Medicare OPPS,40.75,100,,,fee schedule,Pays 100% Medicare OPPS,40.75,100,,,fee schedule,Pays 100% Medicare OPPS,52.97,130,,,fee schedule,Pays 130% Medicare OPPS,61.69,120.37,,,fee schedule,120.37% of custom fee schedule,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,41.56,102,,,fee schedule,Pays 102% Medicare OPPS,472.5,90,,,percent of total billed charges,90% of total billed charges,64.15,125.18,,,fee schedule,125.18% of custom fee schedule,360.68,68.7,,,percent of total billed charges,68.7% of total billed charges,420,80,,,percent of total billed charges,80 percent of total billed charges,40.75,100,,,fee schedule,Pays 100% Medicare OPPS,36.67,90,,,fee schedule,Pays 90% Medicare OPPS,304.5,58,,,percent of total billed charges,58% of total billed charges,61.69,120.37,,,fee schedule,120.37% of custom fee schedule,40.75,100,,,fee schedule,Pays 100% Medicare OPPS,52.97,130,,,fee schedule,Pays 130% Medicare OPPS,446.25,85,,,percent of total billed charges,85% of total billed charges,40.75,100,,,fee schedule,Pays 100% Medicare OPPS,36.67,472.5,
GD1a IgM,3000122,CDM,301,RC,83520,HCPCS,Outpatient,,,525,420,,446.25,85,,,percent of total billed charges,85% of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,130,,,fee schedule,Pays 130% Medicare OPPS,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.61,102,,,fee schedule,Pays 102% Medicare OPPS,472.5,90,,,percent of total billed charges,90% of total billed charges,20.38,125.18,,,fee schedule,125.18% of custom fee schedule,360.68,68.7,,,percent of total billed charges,68.7% of total billed charges,420,80,,,percent of total billed charges,80 percent of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,15.54,90,,,fee schedule,Pays 90% Medicare OPPS,304.5,58,,,percent of total billed charges,58% of total billed charges,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,130,,,fee schedule,Pays 130% Medicare OPPS,446.25,85,,,percent of total billed charges,85% of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,15.54,472.5,
.INFECTIOUS AGENT BY NA AP,3000170,CDM,306,RC,87798,HCPCS,Outpatient,,,525,420,,446.25,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,,,fee schedule,Pays 130% Medicare OPPS,29.7,120.37,,,fee schedule,120.37% of custom fee schedule,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,35.79,102,,,fee schedule,Pays 102% Medicare OPPS,472.5,90,,,percent of total billed charges,90% of total billed charges,30.88,125.18,,,fee schedule,125.18% of custom fee schedule,360.68,68.7,,,percent of total billed charges,68.7% of total billed charges,420,80,,,percent of total billed charges,80 percent of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,31.58,90,,,fee schedule,Pays 90% Medicare OPPS,304.5,58,,,percent of total billed charges,58% of total billed charges,29.7,120.37,,,fee schedule,120.37% of custom fee schedule,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,,,fee schedule,Pays 130% Medicare OPPS,446.25,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,29.7,472.5,
PTH INTRAOPERATIVE,3000246,CDM,301,RC,83970,HCPCS,Outpatient,,,525,420,,446.25,85,,,percent of total billed charges,85% of total billed charges,41.28,100,,,fee schedule,Pays 100% Medicare OPPS,41.28,100,,,fee schedule,Pays 100% Medicare OPPS,41.28,100,,,fee schedule,Pays 100% Medicare OPPS,53.66,130,,,fee schedule,Pays 130% Medicare OPPS,62.47,120.37,,,fee schedule,120.37% of custom fee schedule,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.1,102,,,fee schedule,Pays 102% Medicare OPPS,472.5,90,,,percent of total billed charges,90% of total billed charges,64.97,125.18,,,fee schedule,125.18% of custom fee schedule,360.68,68.7,,,percent of total billed charges,68.7% of total billed charges,420,80,,,percent of total billed charges,80 percent of total billed charges,41.28,100,,,fee schedule,Pays 100% Medicare OPPS,37.15,90,,,fee schedule,Pays 90% Medicare OPPS,304.5,58,,,percent of total billed charges,58% of total billed charges,62.47,120.37,,,fee schedule,120.37% of custom fee schedule,41.28,100,,,fee schedule,Pays 100% Medicare OPPS,53.66,130,,,fee schedule,Pays 130% Medicare OPPS,446.25,85,,,percent of total billed charges,85% of total billed charges,41.28,100,,,fee schedule,Pays 100% Medicare OPPS,37.15,472.5,
GM1 IgG,3000345,CDM,301,RC,83520,HCPCS,Outpatient,,,525,420,,446.25,85,,,percent of total billed charges,85% of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,130,,,fee schedule,Pays 130% Medicare OPPS,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.61,102,,,fee schedule,Pays 102% Medicare OPPS,472.5,90,,,percent of total billed charges,90% of total billed charges,20.38,125.18,,,fee schedule,125.18% of custom fee schedule,360.68,68.7,,,percent of total billed charges,68.7% of total billed charges,420,80,,,percent of total billed charges,80 percent of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,15.54,90,,,fee schedule,Pays 90% Medicare OPPS,304.5,58,,,percent of total billed charges,58% of total billed charges,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,130,,,fee schedule,Pays 130% Medicare OPPS,446.25,85,,,percent of total billed charges,85% of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,15.54,472.5,
APOE GENOTYPE,3000586,CDM,301,RC,81401,HCPCS,Outpatient,,,525,420,,446.25,85,,,percent of total billed charges,85% of total billed charges,137,100,,,fee schedule,Pays 100% Medicare OPPS,137,100,,,fee schedule,Pays 100% Medicare OPPS,137,100,,,fee schedule,Pays 100% Medicare OPPS,178.1,130,,,fee schedule,Pays 130% Medicare OPPS,134.81,120.37,,,fee schedule,120.37% of custom fee schedule,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,139.74,102,,,fee schedule,Pays 102% Medicare OPPS,472.5,90,,,percent of total billed charges,90% of total billed charges,140.2,125.18,,,fee schedule,125.18% of custom fee schedule,360.68,68.7,,,percent of total billed charges,68.7% of total billed charges,420,80,,,percent of total billed charges,80 percent of total billed charges,137,100,,,fee schedule,Pays 100% Medicare OPPS,123.3,90,,,fee schedule,Pays 90% Medicare OPPS,304.5,58,,,percent of total billed charges,58% of total billed charges,134.81,120.37,,,fee schedule,120.37% of custom fee schedule,137,100,,,fee schedule,Pays 100% Medicare OPPS,178.1,130,,,fee schedule,Pays 130% Medicare OPPS,446.25,85,,,percent of total billed charges,85% of total billed charges,137,100,,,fee schedule,Pays 100% Medicare OPPS,123.3,472.5,
3RD METHYLMALONIC ACID URINE,3000653,CDM,301,RC,83921,HCPCS,Outpatient,,,525,420,,446.25,85,,,percent of total billed charges,85% of total billed charges,21.21,100,,,fee schedule,Pays 100% Medicare OPPS,21.21,100,,,fee schedule,Pays 100% Medicare OPPS,21.21,100,,,fee schedule,Pays 100% Medicare OPPS,27.57,130,,,fee schedule,Pays 130% Medicare OPPS,24.92,120.37,,,fee schedule,120.37% of custom fee schedule,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,21.63,102,,,fee schedule,Pays 102% Medicare OPPS,472.5,90,,,percent of total billed charges,90% of total billed charges,25.91,125.18,,,fee schedule,125.18% of custom fee schedule,360.68,68.7,,,percent of total billed charges,68.7% of total billed charges,420,80,,,percent of total billed charges,80 percent of total billed charges,21.21,100,,,fee schedule,Pays 100% Medicare OPPS,19.08,90,,,fee schedule,Pays 90% Medicare OPPS,304.5,58,,,percent of total billed charges,58% of total billed charges,24.92,120.37,,,fee schedule,120.37% of custom fee schedule,21.21,100,,,fee schedule,Pays 100% Medicare OPPS,27.57,130,,,fee schedule,Pays 130% Medicare OPPS,446.25,85,,,percent of total billed charges,85% of total billed charges,21.21,100,,,fee schedule,Pays 100% Medicare OPPS,19.08,472.5,
3RD HEP E VIRUS,3000813,CDM,306,RC,86790,HCPCS,Outpatient,,,525,420,,446.25,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.13,102,,,fee schedule,Pays 102% Medicare OPPS,472.5,90,,,percent of total billed charges,90% of total billed charges,20.28,125.18,,,fee schedule,125.18% of custom fee schedule,360.68,68.7,,,percent of total billed charges,68.7% of total billed charges,420,80,,,percent of total billed charges,80 percent of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,90,,,fee schedule,Pays 90% Medicare OPPS,304.5,58,,,percent of total billed charges,58% of total billed charges,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,446.25,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,472.5,
3RD METHYLMALONIC ACID SERUM,3083921,CDM,301,RC,83921,HCPCS,Outpatient,,,525,420,,446.25,85,,,percent of total billed charges,85% of total billed charges,21.21,100,,,fee schedule,Pays 100% Medicare OPPS,21.21,100,,,fee schedule,Pays 100% Medicare OPPS,21.21,100,,,fee schedule,Pays 100% Medicare OPPS,27.57,130,,,fee schedule,Pays 130% Medicare OPPS,24.92,120.37,,,fee schedule,120.37% of custom fee schedule,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,21.63,102,,,fee schedule,Pays 102% Medicare OPPS,472.5,90,,,percent of total billed charges,90% of total billed charges,25.91,125.18,,,fee schedule,125.18% of custom fee schedule,360.68,68.7,,,percent of total billed charges,68.7% of total billed charges,420,80,,,percent of total billed charges,80 percent of total billed charges,21.21,100,,,fee schedule,Pays 100% Medicare OPPS,19.08,90,,,fee schedule,Pays 90% Medicare OPPS,304.5,58,,,percent of total billed charges,58% of total billed charges,24.92,120.37,,,fee schedule,120.37% of custom fee schedule,21.21,100,,,fee schedule,Pays 100% Medicare OPPS,27.57,130,,,fee schedule,Pays 130% Medicare OPPS,446.25,85,,,percent of total billed charges,85% of total billed charges,21.21,100,,,fee schedule,Pays 100% Medicare OPPS,19.08,472.5,
OPIATES LEVEL,3083925,CDM,302,RC,80365,HCPCS,Outpatient,,,525,420,,446.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,106.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,472.5,90,,,percent of total billed charges,90% of total billed charges,183.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,360.68,68.7,,,percent of total billed charges,68.7% of total billed charges,420,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,304.5,58,,,percent of total billed charges,58% of total billed charges,106.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,446.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,106.94,472.5,
C1Q BINDING ASSAY,3086332,CDM,302,RC,86332,HCPCS,Outpatient,,,525,420,,446.25,85,,,percent of total billed charges,85% of total billed charges,24.37,100,,,fee schedule,Pays 100% Medicare OPPS,24.37,100,,,fee schedule,Pays 100% Medicare OPPS,24.37,100,,,fee schedule,Pays 100% Medicare OPPS,31.68,130,,,fee schedule,Pays 130% Medicare OPPS,36.89,120.37,,,fee schedule,120.37% of custom fee schedule,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,24.85,102,,,fee schedule,Pays 102% Medicare OPPS,472.5,90,,,percent of total billed charges,90% of total billed charges,38.37,125.18,,,fee schedule,125.18% of custom fee schedule,360.68,68.7,,,percent of total billed charges,68.7% of total billed charges,420,80,,,percent of total billed charges,80 percent of total billed charges,24.37,100,,,fee schedule,Pays 100% Medicare OPPS,21.93,90,,,fee schedule,Pays 90% Medicare OPPS,304.5,58,,,percent of total billed charges,58% of total billed charges,36.89,120.37,,,fee schedule,120.37% of custom fee schedule,24.37,100,,,fee schedule,Pays 100% Medicare OPPS,31.68,130,,,fee schedule,Pays 130% Medicare OPPS,446.25,85,,,percent of total billed charges,85% of total billed charges,24.37,100,,,fee schedule,Pays 100% Medicare OPPS,21.93,472.5,
COXIELLA BURNETII IGM ABS,3086638,CDM,302,RC,86638,HCPCS,Outpatient,,,525,420,,446.25,85,,,percent of total billed charges,85% of total billed charges,12.12,100,,,fee schedule,Pays 100% Medicare OPPS,12.12,100,,,fee schedule,Pays 100% Medicare OPPS,12.12,100,,,fee schedule,Pays 100% Medicare OPPS,15.75,130,,,fee schedule,Pays 130% Medicare OPPS,18.36,120.37,,,fee schedule,120.37% of custom fee schedule,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.36,102,,,fee schedule,Pays 102% Medicare OPPS,472.5,90,,,percent of total billed charges,90% of total billed charges,19.09,125.18,,,fee schedule,125.18% of custom fee schedule,360.68,68.7,,,percent of total billed charges,68.7% of total billed charges,420,80,,,percent of total billed charges,80 percent of total billed charges,12.12,100,,,fee schedule,Pays 100% Medicare OPPS,10.9,90,,,fee schedule,Pays 90% Medicare OPPS,304.5,58,,,percent of total billed charges,58% of total billed charges,18.36,120.37,,,fee schedule,120.37% of custom fee schedule,12.12,100,,,fee schedule,Pays 100% Medicare OPPS,15.75,130,,,fee schedule,Pays 130% Medicare OPPS,446.25,85,,,percent of total billed charges,85% of total billed charges,12.12,100,,,fee schedule,Pays 100% Medicare OPPS,10.9,472.5,
3RD CLOSTRIDIUM DIFFICILE PCR,3087493,CDM,306,RC,87493,HCPCS,Outpatient,,,525,420,,446.25,85,,,percent of total billed charges,85% of total billed charges,37.27,100,,,fee schedule,Pays 100% Medicare OPPS,37.27,100,,,fee schedule,Pays 100% Medicare OPPS,37.27,100,,,fee schedule,Pays 100% Medicare OPPS,48.45,130,,,fee schedule,Pays 130% Medicare OPPS,106.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,38.01,102,,,fee schedule,Pays 102% Medicare OPPS,472.5,90,,,percent of total billed charges,90% of total billed charges,183.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,360.68,68.7,,,percent of total billed charges,68.7% of total billed charges,420,80,,,percent of total billed charges,80 percent of total billed charges,37.27,100,,,fee schedule,Pays 100% Medicare OPPS,33.54,90,,,fee schedule,Pays 90% Medicare OPPS,304.5,58,,,percent of total billed charges,58% of total billed charges,106.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,37.27,100,,,fee schedule,Pays 100% Medicare OPPS,48.45,130,,,fee schedule,Pays 130% Medicare OPPS,446.25,85,,,percent of total billed charges,85% of total billed charges,37.27,100,,,fee schedule,Pays 100% Medicare OPPS,33.54,472.5,
OBSERVATION 1ST HR,4000001,CDM,720,RC,99219,HCPCS,Outpatient,,,525,420,,446.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,106.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,472.5,90,,,percent of total billed charges,90% of total billed charges,183.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,360.68,68.7,,,percent of total billed charges,68.7% of total billed charges,420,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,304.5,58,,,percent of total billed charges,58% of total billed charges,106.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,446.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,106.94,472.5,
XR T-M JOINTS TOMO/BILATERAL,4070330,CDM,320,RC,70330,HCPCS,Outpatient,,,525,420,,446.25,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,106.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,295.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,472.5,90,,,percent of total billed charges,90% of total billed charges,183.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,360.68,68.7,,,percent of total billed charges,68.7% of total billed charges,420,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,304.5,58,,,percent of total billed charges,58% of total billed charges,106.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,446.25,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,472.5,
MM DIGITAL SPOT MAG BILATERAL,4300004,CDM,401,RC,G0206,HCPCS,Outpatient,,,525,420,,446.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,106.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,295.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,472.5,90,,,percent of total billed charges,90% of total billed charges,183.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,360.68,68.7,,,percent of total billed charges,68.7% of total billed charges,420,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,304.5,58,,,percent of total billed charges,58% of total billed charges,106.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,446.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,106.94,472.5,
ENDOSCOPIC CLIP APPLIER,7950221,CDM,270,RC,,,Outpatient,,,525,420,,446.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,106.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,296.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,472.5,90,,,percent of total billed charges,90% of total billed charges,183.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,360.68,68.7,,,percent of total billed charges,68.7% of total billed charges,420,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,304.5,58,,,percent of total billed charges,58% of total billed charges,106.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,446.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,106.94,472.5,
CAST LONG ARM QK C,2029065,CDM,450,RC,29065,HCPCS,Outpatient,,,540,432,,459,85,,,percent of total billed charges,85% of total billed charges,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,274.32,130,,,fee schedule,Pays 130% Medicare OPPS,110,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,221.03,102,,,fee schedule,Pays 102% Medicare OPPS,486,90,,,percent of total billed charges,90% of total billed charges,189,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,370.98,68.7,,,percent of total billed charges,68.7% of total billed charges,432,80,,,percent of total billed charges,80 percent of total billed charges,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,195.03,90,,,fee schedule,Pays 90% Medicare OPPS,313.2,58,,,percent of total billed charges,58% of total billed charges,110,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,211.02,100,,,fee schedule,Pays 100% Medicare OPPS,274.32,130,,,fee schedule,Pays 130% Medicare OPPS,459,85,,,percent of total billed charges,85% of total billed charges,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,110,486,
CAST SHORT LEG QK C,2029405,CDM,450,RC,29405,HCPCS,Outpatient,,,540,432,,459,85,,,percent of total billed charges,85% of total billed charges,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,274.32,130,,,fee schedule,Pays 130% Medicare OPPS,110,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,221.03,102,,,fee schedule,Pays 102% Medicare OPPS,486,90,,,percent of total billed charges,90% of total billed charges,189,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,370.98,68.7,,,percent of total billed charges,68.7% of total billed charges,432,80,,,percent of total billed charges,80 percent of total billed charges,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,195.03,90,,,fee schedule,Pays 90% Medicare OPPS,313.2,58,,,percent of total billed charges,58% of total billed charges,110,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,211.02,100,,,fee schedule,Pays 100% Medicare OPPS,274.32,130,,,fee schedule,Pays 130% Medicare OPPS,459,85,,,percent of total billed charges,85% of total billed charges,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,110,486,
3RD PORPHYRINS PLASMA,3000614,CDM,301,RC,80367,HCPCS,Outpatient,,,540,432,,459,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,110,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,486,90,,,percent of total billed charges,90% of total billed charges,189,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,370.98,68.7,,,percent of total billed charges,68.7% of total billed charges,432,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,313.2,58,,,percent of total billed charges,58% of total billed charges,110,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,459,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,110,486,
"BENZODIAZEPINE, SERUM",3080154,CDM,301,RC,80346,HCPCS,Outpatient,,,540,432,,459,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,28,120.37,,,fee schedule,120.37% of custom fee schedule,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,486,90,,,percent of total billed charges,90% of total billed charges,29.12,125.18,,,fee schedule,125.18% of custom fee schedule,370.98,68.7,,,percent of total billed charges,68.7% of total billed charges,432,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,313.2,58,,,percent of total billed charges,58% of total billed charges,28,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,459,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,28,486,
PROTEIN C ACT RESISTANCE LEVEL,3085335,CDM,305,RC,85335,HCPCS,Outpatient,,,540,432,,459,85,,,percent of total billed charges,85% of total billed charges,12.87,100,,,fee schedule,Pays 100% Medicare OPPS,12.87,100,,,fee schedule,Pays 100% Medicare OPPS,12.87,100,,,fee schedule,Pays 100% Medicare OPPS,16.73,130,,,fee schedule,Pays 130% Medicare OPPS,19.49,120.37,,,fee schedule,120.37% of custom fee schedule,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.12,102,,,fee schedule,Pays 102% Medicare OPPS,486,90,,,percent of total billed charges,90% of total billed charges,20.27,125.18,,,fee schedule,125.18% of custom fee schedule,370.98,68.7,,,percent of total billed charges,68.7% of total billed charges,432,80,,,percent of total billed charges,80 percent of total billed charges,12.87,100,,,fee schedule,Pays 100% Medicare OPPS,11.58,90,,,fee schedule,Pays 90% Medicare OPPS,313.2,58,,,percent of total billed charges,58% of total billed charges,19.49,120.37,,,fee schedule,120.37% of custom fee schedule,12.87,100,,,fee schedule,Pays 100% Medicare OPPS,16.73,130,,,fee schedule,Pays 130% Medicare OPPS,459,85,,,percent of total billed charges,85% of total billed charges,12.87,100,,,fee schedule,Pays 100% Medicare OPPS,11.58,486,
"LYME DISEASE IgG, IgM CSF",3086617,CDM,302,RC,86617,HCPCS,Outpatient,,,540,432,,459,85,,,percent of total billed charges,85% of total billed charges,15.49,100,,,fee schedule,Pays 100% Medicare OPPS,15.49,100,,,fee schedule,Pays 100% Medicare OPPS,15.49,100,,,fee schedule,Pays 100% Medicare OPPS,20.13,130,,,fee schedule,Pays 130% Medicare OPPS,23.45,120.37,,,fee schedule,120.37% of custom fee schedule,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,15.79,102,,,fee schedule,Pays 102% Medicare OPPS,486,90,,,percent of total billed charges,90% of total billed charges,24.39,125.18,,,fee schedule,125.18% of custom fee schedule,370.98,68.7,,,percent of total billed charges,68.7% of total billed charges,432,80,,,percent of total billed charges,80 percent of total billed charges,15.49,100,,,fee schedule,Pays 100% Medicare OPPS,13.94,90,,,fee schedule,Pays 90% Medicare OPPS,313.2,58,,,percent of total billed charges,58% of total billed charges,23.45,120.37,,,fee schedule,120.37% of custom fee schedule,15.49,100,,,fee schedule,Pays 100% Medicare OPPS,20.13,130,,,fee schedule,Pays 130% Medicare OPPS,459,85,,,percent of total billed charges,85% of total billed charges,15.49,100,,,fee schedule,Pays 100% Medicare OPPS,13.94,486,
"Radiologic examination of the middle spine, 2 views",4072070,CDM,320,RC,72070,HCPCS,Outpatient,,,540,432,,459,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,110,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,303.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,486,90,,,percent of total billed charges,90% of total billed charges,189,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,370.98,68.7,,,percent of total billed charges,68.7% of total billed charges,432,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,313.2,58,,,percent of total billed charges,58% of total billed charges,110,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,459,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,486,
XR SCOLIOSIS SURVEY,4072090,CDM,320,RC,72082,HCPCS,Outpatient,,,540,432,,459,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,110,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,303.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,486,90,,,percent of total billed charges,90% of total billed charges,189,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,370.98,68.7,,,percent of total billed charges,68.7% of total billed charges,432,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,313.2,58,,,percent of total billed charges,58% of total billed charges,110,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,459,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,486,
X-ray of the lower spine 2-3 views,4072100,CDM,320,RC,72100,HCPCS,Outpatient,,,540,432,,459,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,110,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,303.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,486,90,,,percent of total billed charges,90% of total billed charges,189,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,370.98,68.7,,,percent of total billed charges,68.7% of total billed charges,432,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,313.2,58,,,percent of total billed charges,58% of total billed charges,110,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,459,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,486,
XR SPINE/LUMBAR FLEX EX ONLY,4072120,CDM,320,RC,72120,HCPCS,Outpatient,,,540,432,,459,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,110,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,303.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,486,90,,,percent of total billed charges,90% of total billed charges,189,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,370.98,68.7,,,percent of total billed charges,68.7% of total billed charges,432,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,313.2,58,,,percent of total billed charges,58% of total billed charges,110,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,459,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,486,
GASTROINTESTINAL ANCHOR SET,7950204,CDM,270,RC,,,Outpatient,,,540,432,,459,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,110,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,305.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,486,90,,,percent of total billed charges,90% of total billed charges,189,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,370.98,68.7,,,percent of total billed charges,68.7% of total billed charges,432,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,313.2,58,,,percent of total billed charges,58% of total billed charges,110,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,459,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,110,486,
FOLEY CATH INSERTION COMPLIC,1051703,CDM,762,RC,51703,HCPCS,Outpatient,,,545,436,,463.25,85,,,percent of total billed charges,85% of total billed charges,125.42,100,,,fee schedule,Pays 100% Medicare OPPS,125.42,100,,,fee schedule,Pays 100% Medicare OPPS,125.42,100,,,fee schedule,Pays 100% Medicare OPPS,166.28,130,,,fee schedule,Pays 130% Medicare OPPS,111.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,127.92,102,,,fee schedule,Pays 102% Medicare OPPS,490.5,90,,,percent of total billed charges,90% of total billed charges,190.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,374.42,68.7,,,percent of total billed charges,68.7% of total billed charges,436,80,,,percent of total billed charges,80 percent of total billed charges,125.42,100,,,fee schedule,Pays 100% Medicare OPPS,112.87,90,,,fee schedule,Pays 90% Medicare OPPS,316.1,58,,,percent of total billed charges,58% of total billed charges,111.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,127.91,100,,,fee schedule,Pays 100% Medicare OPPS,166.28,130,,,fee schedule,Pays 130% Medicare OPPS,463.25,85,,,percent of total billed charges,85% of total billed charges,125.42,100,,,fee schedule,Pays 100% Medicare OPPS,111.02,490.5,
FOLEY CATH INSERTION DIFF,2051703,CDM,450,RC,51703,HCPCS,Outpatient,,,545,436,,463.25,85,,,percent of total billed charges,85% of total billed charges,125.42,100,,,fee schedule,Pays 100% Medicare OPPS,125.42,100,,,fee schedule,Pays 100% Medicare OPPS,125.42,100,,,fee schedule,Pays 100% Medicare OPPS,166.28,130,,,fee schedule,Pays 130% Medicare OPPS,111.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,127.92,102,,,fee schedule,Pays 102% Medicare OPPS,490.5,90,,,percent of total billed charges,90% of total billed charges,190.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,374.42,68.7,,,percent of total billed charges,68.7% of total billed charges,436,80,,,percent of total billed charges,80 percent of total billed charges,125.42,100,,,fee schedule,Pays 100% Medicare OPPS,112.87,90,,,fee schedule,Pays 90% Medicare OPPS,316.1,58,,,percent of total billed charges,58% of total billed charges,111.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,127.91,100,,,fee schedule,Pays 100% Medicare OPPS,166.28,130,,,fee schedule,Pays 130% Medicare OPPS,463.25,85,,,percent of total billed charges,85% of total billed charges,125.42,100,,,fee schedule,Pays 100% Medicare OPPS,111.02,490.5,
DEPO-PROVERA (MEDROXYPROGEST)INJ 150MG,2603046,CDM,636,RC,,,Both,,,545,436,,463.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,111.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,490.5,90,,,percent of total billed charges,90% of total billed charges,190.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,374.42,68.7,,,percent of total billed charges,68.7% of total billed charges,436,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,316.1,58,,,percent of total billed charges,58% of total billed charges,111.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,463.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,490.5,
FIORINAL LEVEL,3000034,CDM,301,RC,80345,HCPCS,Outpatient,,,545,436,,463.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,17.35,120.37,,,fee schedule,120.37% of custom fee schedule,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,490.5,90,,,percent of total billed charges,90% of total billed charges,18.04,125.18,,,fee schedule,125.18% of custom fee schedule,374.42,68.7,,,percent of total billed charges,68.7% of total billed charges,436,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,316.1,58,,,percent of total billed charges,58% of total billed charges,17.35,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,463.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,17.35,490.5,
RISPERIDONE LEVEL,3000263,CDM,301,RC,80342,HCPCS,Outpatient,,,545,436,,463.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,23.57,120.37,,,fee schedule,120.37% of custom fee schedule,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,490.5,90,,,percent of total billed charges,90% of total billed charges,24.51,125.18,,,fee schedule,125.18% of custom fee schedule,374.42,68.7,,,percent of total billed charges,68.7% of total billed charges,436,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,316.1,58,,,percent of total billed charges,58% of total billed charges,23.57,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,463.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,23.57,490.5,
"SULFONYLUREA, URINE",3000293,CDM,301,RC,82486,HCPCS,Outpatient,,,545,436,,463.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,111.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,490.5,90,,,percent of total billed charges,90% of total billed charges,190.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,374.42,68.7,,,percent of total billed charges,68.7% of total billed charges,436,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,316.1,58,,,percent of total billed charges,58% of total billed charges,111.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,463.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,111.02,490.5,
"Blood test, comprehensive group of blood chemicals",3000369,CDM,301,RC,80053,HCPCS,Outpatient,,,545,436,,463.25,85,,,percent of total billed charges,85% of total billed charges,10.56,100,,,fee schedule,Pays 100% Medicare OPPS,10.56,100,,,fee schedule,Pays 100% Medicare OPPS,10.56,100,,,fee schedule,Pays 100% Medicare OPPS,13.72,130,,,fee schedule,Pays 130% Medicare OPPS,16,120.37,,,fee schedule,120.37% of custom fee schedule,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,10.77,102,,,fee schedule,Pays 102% Medicare OPPS,490.5,90,,,percent of total billed charges,90% of total billed charges,16.64,125.18,,,fee schedule,125.18% of custom fee schedule,374.42,68.7,,,percent of total billed charges,68.7% of total billed charges,436,80,,,percent of total billed charges,80 percent of total billed charges,10.56,100,,,fee schedule,Pays 100% Medicare OPPS,9.5,90,,,fee schedule,Pays 90% Medicare OPPS,316.1,58,,,percent of total billed charges,58% of total billed charges,16,120.37,,,fee schedule,120.37% of custom fee schedule,10.56,100,,,fee schedule,Pays 100% Medicare OPPS,13.72,130,,,fee schedule,Pays 130% Medicare OPPS,463.25,85,,,percent of total billed charges,85% of total billed charges,10.56,100,,,fee schedule,Pays 100% Medicare OPPS,9.5,490.5,
3RD TRYPSIN LEVEL,3000580,CDM,301,RC,83519,HCPCS,Outpatient,,,545,436,,463.25,85,,,percent of total billed charges,85% of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,23.92,130,,,fee schedule,Pays 130% Medicare OPPS,20.45,120.37,,,fee schedule,120.37% of custom fee schedule,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.76,102,,,fee schedule,Pays 102% Medicare OPPS,490.5,90,,,percent of total billed charges,90% of total billed charges,21.27,125.18,,,fee schedule,125.18% of custom fee schedule,374.42,68.7,,,percent of total billed charges,68.7% of total billed charges,436,80,,,percent of total billed charges,80 percent of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.55,90,,,fee schedule,Pays 90% Medicare OPPS,316.1,58,,,percent of total billed charges,58% of total billed charges,20.45,120.37,,,fee schedule,120.37% of custom fee schedule,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,23.92,130,,,fee schedule,Pays 130% Medicare OPPS,463.25,85,,,percent of total billed charges,85% of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.55,490.5,
"Blood test, comprehensive group of blood chemicals",3080053,CDM,301,RC,80053,HCPCS,Outpatient,,,545,436,,463.25,85,,,percent of total billed charges,85% of total billed charges,10.56,100,,,fee schedule,Pays 100% Medicare OPPS,10.56,100,,,fee schedule,Pays 100% Medicare OPPS,10.56,100,,,fee schedule,Pays 100% Medicare OPPS,13.72,130,,,fee schedule,Pays 130% Medicare OPPS,16,120.37,,,fee schedule,120.37% of custom fee schedule,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,10.77,102,,,fee schedule,Pays 102% Medicare OPPS,490.5,90,,,percent of total billed charges,90% of total billed charges,16.64,125.18,,,fee schedule,125.18% of custom fee schedule,374.42,68.7,,,percent of total billed charges,68.7% of total billed charges,436,80,,,percent of total billed charges,80 percent of total billed charges,10.56,100,,,fee schedule,Pays 100% Medicare OPPS,9.5,90,,,fee schedule,Pays 90% Medicare OPPS,316.1,58,,,percent of total billed charges,58% of total billed charges,16,120.37,,,fee schedule,120.37% of custom fee schedule,10.56,100,,,fee schedule,Pays 100% Medicare OPPS,13.72,130,,,fee schedule,Pays 130% Medicare OPPS,463.25,85,,,percent of total billed charges,85% of total billed charges,10.56,100,,,fee schedule,Pays 100% Medicare OPPS,9.5,490.5,
PROGESTERONE RECEPTOR,3084233,CDM,301,RC,84233,HCPCS,Outpatient,,,545,436,,463.25,85,,,percent of total billed charges,85% of total billed charges,87.88,100,,,fee schedule,Pays 100% Medicare OPPS,87.88,100,,,fee schedule,Pays 100% Medicare OPPS,87.88,100,,,fee schedule,Pays 100% Medicare OPPS,114.24,130,,,fee schedule,Pays 130% Medicare OPPS,97.49,120.37,,,fee schedule,120.37% of custom fee schedule,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,89.63,102,,,fee schedule,Pays 102% Medicare OPPS,490.5,90,,,percent of total billed charges,90% of total billed charges,101.38,125.18,,,fee schedule,125.18% of custom fee schedule,374.42,68.7,,,percent of total billed charges,68.7% of total billed charges,436,80,,,percent of total billed charges,80 percent of total billed charges,87.88,100,,,fee schedule,Pays 100% Medicare OPPS,79.09,90,,,fee schedule,Pays 90% Medicare OPPS,316.1,58,,,percent of total billed charges,58% of total billed charges,97.49,120.37,,,fee schedule,120.37% of custom fee schedule,87.88,100,,,fee schedule,Pays 100% Medicare OPPS,114.24,130,,,fee schedule,Pays 130% Medicare OPPS,463.25,85,,,percent of total billed charges,85% of total billed charges,87.88,100,,,fee schedule,Pays 100% Medicare OPPS,79.09,490.5,
...............PROG RECPT (E&P ASSAY),3084234,CDM,301,RC,84234,HCPCS,Outpatient,,,545,436,,463.25,85,,,percent of total billed charges,85% of total billed charges,64.88,100,,,fee schedule,Pays 100% Medicare OPPS,64.88,100,,,fee schedule,Pays 100% Medicare OPPS,64.88,100,,,fee schedule,Pays 100% Medicare OPPS,84.34,130,,,fee schedule,Pays 130% Medicare OPPS,98.2,120.37,,,fee schedule,120.37% of custom fee schedule,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,66.17,102,,,fee schedule,Pays 102% Medicare OPPS,490.5,90,,,percent of total billed charges,90% of total billed charges,102.12,125.18,,,fee schedule,125.18% of custom fee schedule,374.42,68.7,,,percent of total billed charges,68.7% of total billed charges,436,80,,,percent of total billed charges,80 percent of total billed charges,64.88,100,,,fee schedule,Pays 100% Medicare OPPS,58.39,90,,,fee schedule,Pays 90% Medicare OPPS,316.1,58,,,percent of total billed charges,58% of total billed charges,98.2,120.37,,,fee schedule,120.37% of custom fee schedule,64.88,100,,,fee schedule,Pays 100% Medicare OPPS,84.34,130,,,fee schedule,Pays 130% Medicare OPPS,463.25,85,,,percent of total billed charges,85% of total billed charges,64.88,100,,,fee schedule,Pays 100% Medicare OPPS,58.39,490.5,
Testing for presence of drug,3084392,CDM,301,RC,80307,HCPCS,Outpatient,,,545,436,,463.25,85,,,percent of total billed charges,85% of total billed charges,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,80.78,130,,,fee schedule,Pays 130% Medicare OPPS,73.62,120.37,,,fee schedule,120.37% of custom fee schedule,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,63.38,102,,,fee schedule,Pays 102% Medicare OPPS,490.5,90,,,percent of total billed charges,90% of total billed charges,76.56,125.18,,,fee schedule,125.18% of custom fee schedule,374.42,68.7,,,percent of total billed charges,68.7% of total billed charges,436,80,,,percent of total billed charges,80 percent of total billed charges,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,55.92,90,,,fee schedule,Pays 90% Medicare OPPS,316.1,58,,,percent of total billed charges,58% of total billed charges,73.62,120.37,,,fee schedule,120.37% of custom fee schedule,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,80.78,130,,,fee schedule,Pays 130% Medicare OPPS,463.25,85,,,percent of total billed charges,85% of total billed charges,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,55.92,490.5,
BB FRESH FROZEN PLASMA UNIT,3109017,CDM,390,RC,P9017,HCPCS,Outpatient,,,545,436,,463.25,85,,,percent of total billed charges,85% of total billed charges,84.4,100,,,fee schedule,Pays 100% Medicare OPPS,84.4,100,,,fee schedule,Pays 100% Medicare OPPS,84.4,100,,,fee schedule,Pays 100% Medicare OPPS,111.11,130,,,fee schedule,Pays 130% Medicare OPPS,111.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,307.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,86.08,102,,,fee schedule,Pays 102% Medicare OPPS,490.5,90,,,percent of total billed charges,90% of total billed charges,190.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,374.42,68.7,,,percent of total billed charges,68.7% of total billed charges,436,80,,,percent of total billed charges,80 percent of total billed charges,84.4,100,,,fee schedule,Pays 100% Medicare OPPS,75.95,90,,,fee schedule,Pays 90% Medicare OPPS,316.1,58,,,percent of total billed charges,58% of total billed charges,111.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,85.47,100,,,fee schedule,Pays 100% Medicare OPPS,111.11,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,84.4,100,,,fee schedule,Pays 100% Medicare OPPS,75.95,490.5,
LAP IRRIGATOR,1570013,CDM,270,RC,,,Outpatient,,,550,440,,467.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,112.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,310.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,310.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,310.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,310.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,495,90,,,percent of total billed charges,90% of total billed charges,192.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,377.85,68.7,,,percent of total billed charges,68.7% of total billed charges,440,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,319,58,,,percent of total billed charges,58% of total billed charges,112.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,467.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,112.04,495,
RING MALYUGIN 6.25mm,1570380,CDM,276,RC,,,Outpatient,,,550,440,,467.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,112.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,495,90,,,percent of total billed charges,90% of total billed charges,192.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,377.85,68.7,,,percent of total billed charges,68.7% of total billed charges,440,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,319,58,,,percent of total billed charges,58% of total billed charges,112.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,467.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,495,
LAC SIMPLE < 2.5,2012001,CDM,450,RC,,,Outpatient,,,550,440,,467.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,112.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,310.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,310.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,310.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,310.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,495,90,,,percent of total billed charges,90% of total billed charges,192.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,377.85,68.7,,,percent of total billed charges,68.7% of total billed charges,440,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,319,58,,,percent of total billed charges,58% of total billed charges,112.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,467.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,112.04,495,
LAC INTRM < 2.5 CM,2012031,CDM,450,RC,12031,HCPCS,Outpatient,,,550,440,,467.5,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,112.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,310.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,310.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,310.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,310.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,316.7,102,,,fee schedule,Pays 102% Medicare OPPS,495,90,,,percent of total billed charges,90% of total billed charges,192.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,377.85,68.7,,,percent of total billed charges,68.7% of total billed charges,440,80,,,percent of total billed charges,80 percent of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,279.44,90,,,fee schedule,Pays 90% Medicare OPPS,319,58,,,percent of total billed charges,58% of total billed charges,112.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,328.14,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,467.5,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,112.04,495,
NOSE BLEED CONTROL,2030901,CDM,450,RC,,,Outpatient,,,550,440,,467.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,112.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,310.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,310.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,310.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,310.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,495,90,,,percent of total billed charges,90% of total billed charges,192.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,377.85,68.7,,,percent of total billed charges,68.7% of total billed charges,440,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,319,58,,,percent of total billed charges,58% of total billed charges,112.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,467.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,112.04,495,
GLUCAGON INJ 1MG,2601316,CDM,636,RC,J1610,HCPCS,Both,,,550,440,,467.5,85,,,percent of total billed charges,85% of total billed charges,170.33,100,,,fee schedule,Pays 100% Medicare OPPS,170.33,100,,,fee schedule,Pays 100% Medicare OPPS,170.33,100,,,fee schedule,Pays 100% Medicare OPPS,243.75,130,,,fee schedule,Pays 130% Medicare OPPS,205.03,120.37,,,fee schedule,120.37% of custom fee schedule,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,173.73,102,,,fee schedule,Pays 102% Medicare OPPS,495,90,,,percent of total billed charges,90% of total billed charges,213.22,125.18,,,fee schedule,125.18% of custom fee schedule,377.85,68.7,,,percent of total billed charges,68.7% of total billed charges,440,80,,,percent of total billed charges,80 percent of total billed charges,170.33,100,,,fee schedule,Pays 100% Medicare OPPS,153.29,90,,,fee schedule,Pays 90% Medicare OPPS,319,58,,,percent of total billed charges,58% of total billed charges,205.03,120.37,,,fee schedule,120.37% of custom fee schedule,187.5,100,,,fee schedule,Pays 100% Medicare OPPS,243.75,130,,,fee schedule,Pays 130% Medicare OPPS,467.5,85,,,percent of total billed charges,85% of total billed charges,170.33,100,,,fee schedule,Pays 100% Medicare OPPS,0.01,495,
.MOLECULAR CYTO 25-99 CELL,3088274,CDM,311,RC,88274,HCPCS,Outpatient,,,550,440,,467.5,85,,,percent of total billed charges,85% of total billed charges,42.38,100,,,fee schedule,Pays 100% Medicare OPPS,42.38,100,,,fee schedule,Pays 100% Medicare OPPS,42.38,100,,,fee schedule,Pays 100% Medicare OPPS,55.09,130,,,fee schedule,Pays 130% Medicare OPPS,52.69,120.37,,,fee schedule,120.37% of custom fee schedule,310.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,310.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,310.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,310.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,43.22,102,,,fee schedule,Pays 102% Medicare OPPS,495,90,,,percent of total billed charges,90% of total billed charges,54.79,125.18,,,fee schedule,125.18% of custom fee schedule,377.85,68.7,,,percent of total billed charges,68.7% of total billed charges,440,80,,,percent of total billed charges,80 percent of total billed charges,42.38,100,,,fee schedule,Pays 100% Medicare OPPS,38.14,90,,,fee schedule,Pays 90% Medicare OPPS,319,58,,,percent of total billed charges,58% of total billed charges,52.69,120.37,,,fee schedule,120.37% of custom fee schedule,42.38,100,,,fee schedule,Pays 100% Medicare OPPS,55.09,130,,,fee schedule,Pays 130% Medicare OPPS,467.5,85,,,percent of total billed charges,85% of total billed charges,42.38,100,,,fee schedule,Pays 100% Medicare OPPS,38.14,495,
LINEAR CUTTER PROXIMATE 75MM TLC75,7950237,CDM,272,RC,,,Outpatient,,,550,440,,467.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,112.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,310.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,310.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,310.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,310.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,495,90,,,percent of total billed charges,90% of total billed charges,192.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,377.85,68.7,,,percent of total billed charges,68.7% of total billed charges,440,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,319,58,,,percent of total billed charges,58% of total billed charges,112.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,467.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,112.04,495,
FLOVENT (FLUTICASONE) HFA INH 110MCG,2610122,CDM,250,RC,,,Outpatient,,,555,444,,471.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,113.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,313.58,56.5,,,percent of total billed charges,56.5 percent of total billed charges,313.58,56.5,,,percent of total billed charges,56.5 percent of total billed charges,313.58,56.5,,,percent of total billed charges,56.5 percent of total billed charges,313.58,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,499.5,90,,,percent of total billed charges,90% of total billed charges,194.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,381.29,68.7,,,percent of total billed charges,68.7% of total billed charges,444,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,321.9,58,,,percent of total billed charges,58% of total billed charges,113.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,471.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,113.05,499.5,
SPLINT GOLDSMITH NASAL,7905952,CDM,270,RC,,,Outpatient,,,560,448,,476,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,114.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,316.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,316.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,316.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,316.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,504,90,,,percent of total billed charges,90% of total billed charges,196,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,384.72,68.7,,,percent of total billed charges,68.7% of total billed charges,448,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,324.8,58,,,percent of total billed charges,58% of total billed charges,114.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,476,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,114.07,504,
STENT ADVANIX PRELOADED RX 7x5CM,1750035,CDM,272,RC,,,Outpatient,,,565,452,,480.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,508.5,90,,,percent of total billed charges,90% of total billed charges,197.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,388.16,68.7,,,percent of total billed charges,68.7% of total billed charges,452,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,327.7,58,,,percent of total billed charges,58% of total billed charges,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,480.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,115.09,508.5,
STENT ADVANIX PRELOADED RX 7x7CM,1750036,CDM,272,RC,,,Outpatient,,,565,452,,480.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,508.5,90,,,percent of total billed charges,90% of total billed charges,197.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,388.16,68.7,,,percent of total billed charges,68.7% of total billed charges,452,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,327.7,58,,,percent of total billed charges,58% of total billed charges,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,480.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,115.09,508.5,
STENT ADVANIX PRELOADED RX 7x9CM,1750037,CDM,272,RC,,,Outpatient,,,565,452,,480.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,508.5,90,,,percent of total billed charges,90% of total billed charges,197.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,388.16,68.7,,,percent of total billed charges,68.7% of total billed charges,452,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,327.7,58,,,percent of total billed charges,58% of total billed charges,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,480.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,115.09,508.5,
STENT ADVANIX PRELOADED RX 10x5CM,1750038,CDM,272,RC,,,Outpatient,,,565,452,,480.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,508.5,90,,,percent of total billed charges,90% of total billed charges,197.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,388.16,68.7,,,percent of total billed charges,68.7% of total billed charges,452,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,327.7,58,,,percent of total billed charges,58% of total billed charges,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,480.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,115.09,508.5,
STENT ADVANIX PRELOADED RX 10x7CM,1750039,CDM,272,RC,,,Outpatient,,,565,452,,480.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,508.5,90,,,percent of total billed charges,90% of total billed charges,197.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,388.16,68.7,,,percent of total billed charges,68.7% of total billed charges,452,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,327.7,58,,,percent of total billed charges,58% of total billed charges,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,480.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,115.09,508.5,
STENT ADVANIX PRELOADED RX 10x9CM,1750040,CDM,272,RC,,,Outpatient,,,565,452,,480.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,508.5,90,,,percent of total billed charges,90% of total billed charges,197.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,388.16,68.7,,,percent of total billed charges,68.7% of total billed charges,452,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,327.7,58,,,percent of total billed charges,58% of total billed charges,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,480.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,115.09,508.5,
3RD RAPAMYCIN/SIROLIMUS,3000250,CDM,300,RC,80195,HCPCS,Outpatient,,,565,452,,480.25,85,,,percent of total billed charges,85% of total billed charges,13.73,100,,,fee schedule,Pays 100% Medicare OPPS,13.73,100,,,fee schedule,Pays 100% Medicare OPPS,13.73,100,,,fee schedule,Pays 100% Medicare OPPS,17.84,130,,,fee schedule,Pays 130% Medicare OPPS,20.76,120.37,,,fee schedule,120.37% of custom fee schedule,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14,102,,,fee schedule,Pays 102% Medicare OPPS,508.5,90,,,percent of total billed charges,90% of total billed charges,21.59,125.18,,,fee schedule,125.18% of custom fee schedule,388.16,68.7,,,percent of total billed charges,68.7% of total billed charges,452,80,,,percent of total billed charges,80 percent of total billed charges,13.73,100,,,fee schedule,Pays 100% Medicare OPPS,12.35,90,,,fee schedule,Pays 90% Medicare OPPS,327.7,58,,,percent of total billed charges,58% of total billed charges,20.76,120.37,,,fee schedule,120.37% of custom fee schedule,13.73,100,,,fee schedule,Pays 100% Medicare OPPS,17.84,130,,,fee schedule,Pays 130% Medicare OPPS,480.25,85,,,percent of total billed charges,85% of total billed charges,13.73,100,,,fee schedule,Pays 100% Medicare OPPS,12.35,508.5,
H PYLORI STOOL ANTIGEN,3087338,CDM,302,RC,87338,HCPCS,Outpatient,,,565,452,,480.25,85,,,percent of total billed charges,85% of total billed charges,14.38,100,,,fee schedule,Pays 100% Medicare OPPS,14.38,100,,,fee schedule,Pays 100% Medicare OPPS,14.38,100,,,fee schedule,Pays 100% Medicare OPPS,18.69,130,,,fee schedule,Pays 130% Medicare OPPS,21.77,120.37,,,fee schedule,120.37% of custom fee schedule,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.66,102,,,fee schedule,Pays 102% Medicare OPPS,508.5,90,,,percent of total billed charges,90% of total billed charges,22.65,125.18,,,fee schedule,125.18% of custom fee schedule,388.16,68.7,,,percent of total billed charges,68.7% of total billed charges,452,80,,,percent of total billed charges,80 percent of total billed charges,14.38,100,,,fee schedule,Pays 100% Medicare OPPS,12.94,90,,,fee schedule,Pays 90% Medicare OPPS,327.7,58,,,percent of total billed charges,58% of total billed charges,21.77,120.37,,,fee schedule,120.37% of custom fee schedule,14.38,100,,,fee schedule,Pays 100% Medicare OPPS,18.69,130,,,fee schedule,Pays 130% Medicare OPPS,480.25,85,,,percent of total billed charges,85% of total billed charges,14.38,100,,,fee schedule,Pays 100% Medicare OPPS,12.94,508.5,
Radiologic examination of the knee with 4 or more views,4003564,CDM,320,RC,73564,HCPCS,Outpatient,,,565,452,,480.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,317.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,508.5,90,,,percent of total billed charges,90% of total billed charges,197.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,388.16,68.7,,,percent of total billed charges,68.7% of total billed charges,452,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,327.7,58,,,percent of total billed charges,58% of total billed charges,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,480.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,508.5,
XR INJECTION PROCEDURE FOR SIALOGRAPHY,4042550,CDM,324,RC,42550,HCPCS,Outpatient,,,565,452,,480.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,317.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,508.5,90,,,percent of total billed charges,90% of total billed charges,197.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,388.16,68.7,,,percent of total billed charges,68.7% of total billed charges,452,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,327.7,58,,,percent of total billed charges,58% of total billed charges,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,480.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,115.09,508.5,
XR MANDIBLE 4 VIEWS COMPLETE,4070110,CDM,320,RC,70110,HCPCS,Outpatient,,,565,452,,480.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,317.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,508.5,90,,,percent of total billed charges,90% of total billed charges,197.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,388.16,68.7,,,percent of total billed charges,68.7% of total billed charges,452,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,327.7,58,,,percent of total billed charges,58% of total billed charges,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,480.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,508.5,
XR ORBITS 4 VIEWS,4070200,CDM,320,RC,70200,HCPCS,Outpatient,,,565,452,,480.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,317.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,508.5,90,,,percent of total billed charges,90% of total billed charges,197.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,388.16,68.7,,,percent of total billed charges,68.7% of total billed charges,452,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,327.7,58,,,percent of total billed charges,58% of total billed charges,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,480.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,508.5,
XR SINUSES 4 VIEWS,4070220,CDM,320,RC,70220,HCPCS,Outpatient,,,565,452,,480.25,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,317.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,508.5,90,,,percent of total billed charges,90% of total billed charges,197.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,388.16,68.7,,,percent of total billed charges,68.7% of total billed charges,452,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,327.7,58,,,percent of total billed charges,58% of total billed charges,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,480.25,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,508.5,
XR SKULL/LTD 2 VIEWS,4070250,CDM,320,RC,70250,HCPCS,Outpatient,,,565,452,,480.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,317.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,508.5,90,,,percent of total billed charges,90% of total billed charges,197.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,388.16,68.7,,,percent of total billed charges,68.7% of total billed charges,452,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,327.7,58,,,percent of total billed charges,58% of total billed charges,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,480.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,508.5,
3 views,4071021,CDM,324,RC,71047,HCPCS,Outpatient,,,565,452,,480.25,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,317.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,508.5,90,,,percent of total billed charges,90% of total billed charges,197.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,388.16,68.7,,,percent of total billed charges,68.7% of total billed charges,452,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,327.7,58,,,percent of total billed charges,58% of total billed charges,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,480.25,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,508.5,
XR PELVIS/BOTH OBLIQUES 3 VW,4072190,CDM,320,RC,72190,HCPCS,Outpatient,,,565,452,,480.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,317.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,508.5,90,,,percent of total billed charges,90% of total billed charges,197.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,388.16,68.7,,,percent of total billed charges,68.7% of total billed charges,452,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,327.7,58,,,percent of total billed charges,58% of total billed charges,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,480.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,508.5,
XR FACIAL BONES 4 VIEWS,4073551,CDM,320,RC,70150,HCPCS,Outpatient,,,565,452,,480.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,317.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,508.5,90,,,percent of total billed charges,90% of total billed charges,197.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,388.16,68.7,,,percent of total billed charges,68.7% of total billed charges,452,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,327.7,58,,,percent of total billed charges,58% of total billed charges,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,480.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,508.5,
Radiologic examination of the knee with 4 or more views,4073564,CDM,320,RC,73564,HCPCS,Outpatient,,,565,452,,480.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,317.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,508.5,90,,,percent of total billed charges,90% of total billed charges,197.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,388.16,68.7,,,percent of total billed charges,68.7% of total billed charges,452,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,327.7,58,,,percent of total billed charges,58% of total billed charges,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,480.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,508.5,
XR CYSTOGRAM,4074455,CDM,320,RC,74430,HCPCS,Outpatient,,,565,452,,480.25,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.28,130,,,fee schedule,Pays 130% Medicare OPPS,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,317.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,508.5,90,,,percent of total billed charges,90% of total billed charges,197.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,388.16,68.7,,,percent of total billed charges,68.7% of total billed charges,452,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,327.7,58,,,percent of total billed charges,58% of total billed charges,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.28,130,,,fee schedule,Pays 130% Medicare OPPS,480.25,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,115.09,508.5,
Radiologic examination of the knee with 4 or more views,4083564,CDM,320,RC,73564,HCPCS,Outpatient,,,565,452,,480.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,319.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,317.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,508.5,90,,,percent of total billed charges,90% of total billed charges,197.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,388.16,68.7,,,percent of total billed charges,68.7% of total billed charges,452,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,327.7,58,,,percent of total billed charges,58% of total billed charges,115.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,480.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,508.5,
NEWBORN RESUSCITATION,502101,CDM,410,RC,99465,HCPCS,Outpatient,,,570,456,,484.5,85,,,percent of total billed charges,85% of total billed charges,504.64,100,,,fee schedule,Pays 100% Medicare OPPS,504.64,100,,,fee schedule,Pays 100% Medicare OPPS,504.64,100,,,fee schedule,Pays 100% Medicare OPPS,672.51,130,,,fee schedule,Pays 130% Medicare OPPS,116.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,322.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,322.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,322.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,322.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,514.73,102,,,fee schedule,Pays 102% Medicare OPPS,513,90,,,percent of total billed charges,90% of total billed charges,199.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,391.59,68.7,,,percent of total billed charges,68.7% of total billed charges,456,80,,,percent of total billed charges,80 percent of total billed charges,504.64,100,,,fee schedule,Pays 100% Medicare OPPS,454.17,90,,,fee schedule,Pays 90% Medicare OPPS,330.6,58,,,percent of total billed charges,58% of total billed charges,116.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,517.3,100,,,fee schedule,Pays 100% Medicare OPPS,672.51,130,,,fee schedule,Pays 130% Medicare OPPS,484.5,85,,,percent of total billed charges,85% of total billed charges,504.64,100,,,fee schedule,Pays 100% Medicare OPPS,116.11,672.51,
RETRACTOR KIT REDD-SAYE,7905770,CDM,270,RC,,,Outpatient,,,570,456,,484.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,116.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,322.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,322.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,322.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,322.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,513,90,,,percent of total billed charges,90% of total billed charges,199.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,391.59,68.7,,,percent of total billed charges,68.7% of total billed charges,456,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,330.6,58,,,percent of total billed charges,58% of total billed charges,116.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,484.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,116.11,513,
SCREW BONE 3.5MM LOCKING SELF TAP 12MM,1570020,CDM,278,RC,C1713,HCPCS,Both,,,575,460,,488.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,517.5,90,,,percent of total billed charges,90% of total billed charges,201.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,395.03,68.7,,,percent of total billed charges,68.7% of total billed charges,460,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,333.5,58,,,percent of total billed charges,58% of total billed charges,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,488.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,517.5,
SCREW BONE 3.5MM LOCKING SELF TAP 14MM,1570021,CDM,278,RC,C1713,HCPCS,Both,,,575,460,,488.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,517.5,90,,,percent of total billed charges,90% of total billed charges,201.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,395.03,68.7,,,percent of total billed charges,68.7% of total billed charges,460,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,333.5,58,,,percent of total billed charges,58% of total billed charges,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,488.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,517.5,
SCREW BONE 3.5MM LOCKING SELF TAP 16MM,1570022,CDM,278,RC,C1713,HCPCS,Both,,,575,460,,488.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,517.5,90,,,percent of total billed charges,90% of total billed charges,201.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,395.03,68.7,,,percent of total billed charges,68.7% of total billed charges,460,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,333.5,58,,,percent of total billed charges,58% of total billed charges,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,488.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,517.5,
SCREW BONE 3.5MM LOCKING SELF TAP 20MM,1570023,CDM,278,RC,C1713,HCPCS,Both,,,575,460,,488.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,517.5,90,,,percent of total billed charges,90% of total billed charges,201.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,395.03,68.7,,,percent of total billed charges,68.7% of total billed charges,460,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,333.5,58,,,percent of total billed charges,58% of total billed charges,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,488.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,517.5,
3RD GLUTAMIC ACID DECARBOXYLA,3000133,CDM,301,RC,83519,HCPCS,Outpatient,,,575,460,,488.75,85,,,percent of total billed charges,85% of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,23.92,130,,,fee schedule,Pays 130% Medicare OPPS,20.45,120.37,,,fee schedule,120.37% of custom fee schedule,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.76,102,,,fee schedule,Pays 102% Medicare OPPS,517.5,90,,,percent of total billed charges,90% of total billed charges,21.27,125.18,,,fee schedule,125.18% of custom fee schedule,395.03,68.7,,,percent of total billed charges,68.7% of total billed charges,460,80,,,percent of total billed charges,80 percent of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.55,90,,,fee schedule,Pays 90% Medicare OPPS,333.5,58,,,percent of total billed charges,58% of total billed charges,20.45,120.37,,,fee schedule,120.37% of custom fee schedule,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,23.92,130,,,fee schedule,Pays 130% Medicare OPPS,488.75,85,,,percent of total billed charges,85% of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.55,517.5,
LEVETIRACETAM,3000187,CDM,301,RC,80177,HCPCS,Outpatient,,,575,460,,488.75,85,,,percent of total billed charges,85% of total billed charges,13.25,100,,,fee schedule,Pays 100% Medicare OPPS,13.25,100,,,fee schedule,Pays 100% Medicare OPPS,13.25,100,,,fee schedule,Pays 100% Medicare OPPS,17.22,130,,,fee schedule,Pays 130% Medicare OPPS,17.42,120.37,,,fee schedule,120.37% of custom fee schedule,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.51,102,,,fee schedule,Pays 102% Medicare OPPS,517.5,90,,,percent of total billed charges,90% of total billed charges,18.11,125.18,,,fee schedule,125.18% of custom fee schedule,395.03,68.7,,,percent of total billed charges,68.7% of total billed charges,460,80,,,percent of total billed charges,80 percent of total billed charges,13.25,100,,,fee schedule,Pays 100% Medicare OPPS,11.92,90,,,fee schedule,Pays 90% Medicare OPPS,333.5,58,,,percent of total billed charges,58% of total billed charges,17.42,120.37,,,fee schedule,120.37% of custom fee schedule,13.25,100,,,fee schedule,Pays 100% Medicare OPPS,17.22,130,,,fee schedule,Pays 130% Medicare OPPS,488.75,85,,,percent of total billed charges,85% of total billed charges,13.25,100,,,fee schedule,Pays 100% Medicare OPPS,11.92,517.5,
"OXYCONTIN, QUANTITATIVE LEVEL",3000224,CDM,301,RC,80365,HCPCS,Outpatient,,,575,460,,488.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,517.5,90,,,percent of total billed charges,90% of total billed charges,201.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,395.03,68.7,,,percent of total billed charges,68.7% of total billed charges,460,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,333.5,58,,,percent of total billed charges,58% of total billed charges,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,488.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,117.13,517.5,
PROLIXIN LVL/FLUPHENAZINE,3000238,CDM,301,RC,80299,HCPCS,Outpatient,,,575,460,,488.75,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.01,102,,,fee schedule,Pays 102% Medicare OPPS,517.5,90,,,percent of total billed charges,90% of total billed charges,18.95,125.18,,,fee schedule,125.18% of custom fee schedule,395.03,68.7,,,percent of total billed charges,68.7% of total billed charges,460,80,,,percent of total billed charges,80 percent of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,90,,,fee schedule,Pays 90% Medicare OPPS,333.5,58,,,percent of total billed charges,58% of total billed charges,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,488.75,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,517.5,
SEROQUEL LEVEL,3000279,CDM,301,RC,80299,HCPCS,Outpatient,,,575,460,,488.75,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.01,102,,,fee schedule,Pays 102% Medicare OPPS,517.5,90,,,percent of total billed charges,90% of total billed charges,18.95,125.18,,,fee schedule,125.18% of custom fee schedule,395.03,68.7,,,percent of total billed charges,68.7% of total billed charges,460,80,,,percent of total billed charges,80 percent of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,90,,,fee schedule,Pays 90% Medicare OPPS,333.5,58,,,percent of total billed charges,58% of total billed charges,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,488.75,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,517.5,
Acute hepatitis panel,3080074,CDM,301,RC,80074,HCPCS,Outpatient,,,575,460,,488.75,85,,,percent of total billed charges,85% of total billed charges,47.63,100,,,fee schedule,Pays 100% Medicare OPPS,47.63,100,,,fee schedule,Pays 100% Medicare OPPS,47.63,100,,,fee schedule,Pays 100% Medicare OPPS,61.91,130,,,fee schedule,Pays 130% Medicare OPPS,72.09,120.37,,,fee schedule,120.37% of custom fee schedule,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,48.58,102,,,fee schedule,Pays 102% Medicare OPPS,517.5,90,,,percent of total billed charges,90% of total billed charges,74.97,125.18,,,fee schedule,125.18% of custom fee schedule,395.03,68.7,,,percent of total billed charges,68.7% of total billed charges,460,80,,,percent of total billed charges,80 percent of total billed charges,47.63,100,,,fee schedule,Pays 100% Medicare OPPS,42.86,90,,,fee schedule,Pays 90% Medicare OPPS,333.5,58,,,percent of total billed charges,58% of total billed charges,72.09,120.37,,,fee schedule,120.37% of custom fee schedule,47.63,100,,,fee schedule,Pays 100% Medicare OPPS,61.91,130,,,fee schedule,Pays 130% Medicare OPPS,488.75,85,,,percent of total billed charges,85% of total billed charges,47.63,100,,,fee schedule,Pays 100% Medicare OPPS,42.86,517.5,
XR HIPS BIL WITH AP/PELVIS,4000016,CDM,320,RC,73521,HCPCS,Outpatient,,,575,460,,488.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,323.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,517.5,90,,,percent of total billed charges,90% of total billed charges,201.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,395.03,68.7,,,percent of total billed charges,68.7% of total billed charges,460,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,333.5,58,,,percent of total billed charges,58% of total billed charges,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,488.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,517.5,
Radiologic examination of one side of the chest/ribs,4071101,CDM,320,RC,71101,HCPCS,Outpatient,,,575,460,,488.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,323.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,517.5,90,,,percent of total billed charges,90% of total billed charges,201.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,395.03,68.7,,,percent of total billed charges,68.7% of total billed charges,460,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,333.5,58,,,percent of total billed charges,58% of total billed charges,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,488.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,517.5,
Radiologic examination of one side of the chest/ribs,4071102,CDM,320,RC,71101,HCPCS,Outpatient,,,575,460,,488.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,323.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,517.5,90,,,percent of total billed charges,90% of total billed charges,201.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,395.03,68.7,,,percent of total billed charges,68.7% of total billed charges,460,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,333.5,58,,,percent of total billed charges,58% of total billed charges,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,488.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,517.5,
Radiologic examination of one side of the chest/ribs,4081101,CDM,320,RC,71101,HCPCS,Outpatient,,,575,460,,488.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,323.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,517.5,90,,,percent of total billed charges,90% of total billed charges,201.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,395.03,68.7,,,percent of total billed charges,68.7% of total billed charges,460,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,333.5,58,,,percent of total billed charges,58% of total billed charges,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,488.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,517.5,
.....CT OPTIRAY PER 100 ML LOW OSMOLAR,4200010,CDM,255,RC,,,Outpatient,,,575,460,,488.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,517.5,90,,,percent of total billed charges,90% of total billed charges,201.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,395.03,68.7,,,percent of total billed charges,68.7% of total billed charges,460,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,333.5,58,,,percent of total billed charges,58% of total billed charges,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,117.13,517.5,
US FETAL < 14 WKS EACH ADDITIONAL,4676802,CDM,402,RC,76802,HCPCS,Outpatient,,,575,460,,488.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,323.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,517.5,90,,,percent of total billed charges,90% of total billed charges,201.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,395.03,68.7,,,percent of total billed charges,68.7% of total billed charges,460,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,333.5,58,,,percent of total billed charges,58% of total billed charges,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,488.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,117.13,517.5,
US FETAL >14 WKS EACH ADDITIONAL FETUS,4676810,CDM,402,RC,76810,HCPCS,Outpatient,,,575,460,,488.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,323.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,517.5,90,,,percent of total billed charges,90% of total billed charges,201.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,395.03,68.7,,,percent of total billed charges,68.7% of total billed charges,460,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,333.5,58,,,percent of total billed charges,58% of total billed charges,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,488.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,117.13,517.5,
ST SPEECH THRPY EVALUAT(PER SESSION),5292506,CDM,440,RC,92506,HCPCS,Outpatient,,,575,460,,488.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,517.5,90,,,percent of total billed charges,90% of total billed charges,201.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,395.03,68.7,,,percent of total billed charges,68.7% of total billed charges,460,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,333.5,58,,,percent of total billed charges,58% of total billed charges,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,488.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,117.13,517.5,
ST SWALLOWING EVALUATION (PER SESSION),5292610,CDM,444,RC,92610,HCPCS,Outpatient,,,575,460,,488.75,85,,,percent of total billed charges,85% of total billed charges,82.11,100,,,fee schedule,Pays 100% Medicare OPPS,82.11,100,,,fee schedule,Pays 100% Medicare OPPS,82.11,100,,,fee schedule,Pays 100% Medicare OPPS,87.78,130,,,fee schedule,Pays 130% Medicare OPPS,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,83.75,102,,,fee schedule,Pays 102% Medicare OPPS,517.5,90,,,percent of total billed charges,90% of total billed charges,201.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,395.03,68.7,,,percent of total billed charges,68.7% of total billed charges,460,80,,,percent of total billed charges,80 percent of total billed charges,82.11,100,,,fee schedule,Pays 100% Medicare OPPS,73.9,90,,,fee schedule,Pays 90% Medicare OPPS,333.5,58,,,percent of total billed charges,58% of total billed charges,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,67.52,100,,,fee schedule,Pays 100% Medicare OPPS,87.78,130,,,fee schedule,Pays 130% Medicare OPPS,488.75,85,,,percent of total billed charges,85% of total billed charges,82.11,100,,,fee schedule,Pays 100% Medicare OPPS,67.52,517.5,
ST MODIFIED BARIUM SWALLOW (PER SESSION),5292611,CDM,440,RC,92611,HCPCS,Outpatient,,,575,460,,488.75,85,,,percent of total billed charges,85% of total billed charges,88.07,100,,,fee schedule,Pays 100% Medicare OPPS,88.07,100,,,fee schedule,Pays 100% Medicare OPPS,88.07,100,,,fee schedule,Pays 100% Medicare OPPS,113.45,130,,,fee schedule,Pays 130% Medicare OPPS,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,89.83,102,,,fee schedule,Pays 102% Medicare OPPS,517.5,90,,,percent of total billed charges,90% of total billed charges,201.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,395.03,68.7,,,percent of total billed charges,68.7% of total billed charges,460,80,,,percent of total billed charges,80 percent of total billed charges,88.07,100,,,fee schedule,Pays 100% Medicare OPPS,79.26,90,,,fee schedule,Pays 90% Medicare OPPS,333.5,58,,,percent of total billed charges,58% of total billed charges,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,87.27,100,,,fee schedule,Pays 100% Medicare OPPS,113.45,130,,,fee schedule,Pays 130% Medicare OPPS,488.75,85,,,percent of total billed charges,85% of total billed charges,88.07,100,,,fee schedule,Pays 100% Medicare OPPS,79.26,517.5,
TROCAR/ENDOPATH 5MM 355LD,7950141,CDM,270,RC,,,Outpatient,,,575,460,,488.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,517.5,90,,,percent of total billed charges,90% of total billed charges,201.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,395.03,68.7,,,percent of total billed charges,68.7% of total billed charges,460,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,333.5,58,,,percent of total billed charges,58% of total billed charges,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,488.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,117.13,517.5,
LINEAR CUTTER RELOAD ECHEL WHITE GST60W,7950287,CDM,272,RC,,,Outpatient,,,575,460,,488.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,517.5,90,,,percent of total billed charges,90% of total billed charges,201.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,395.03,68.7,,,percent of total billed charges,68.7% of total billed charges,460,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,333.5,58,,,percent of total billed charges,58% of total billed charges,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,488.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,117.13,517.5,
LINEAR CUTTER PROXIMATE 75MM TCT75,7950303,CDM,272,RC,,,Outpatient,,,575,460,,488.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,324.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,517.5,90,,,percent of total billed charges,90% of total billed charges,201.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,395.03,68.7,,,percent of total billed charges,68.7% of total billed charges,460,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,333.5,58,,,percent of total billed charges,58% of total billed charges,117.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,488.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,117.13,517.5,
I&D VULVA PERINEAL ABSCESS,2056405,CDM,450,RC,56405,HCPCS,Outpatient,,,585,468,,497.25,85,,,percent of total billed charges,85% of total billed charges,253.35,100,,,fee schedule,Pays 100% Medicare OPPS,253.35,100,,,fee schedule,Pays 100% Medicare OPPS,253.35,100,,,fee schedule,Pays 100% Medicare OPPS,333.83,130,,,fee schedule,Pays 130% Medicare OPPS,119.16,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,330.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,330.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,330.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,330.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,258.42,102,,,fee schedule,Pays 102% Medicare OPPS,526.5,90,,,percent of total billed charges,90% of total billed charges,204.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,401.9,68.7,,,percent of total billed charges,68.7% of total billed charges,468,80,,,percent of total billed charges,80 percent of total billed charges,253.35,100,,,fee schedule,Pays 100% Medicare OPPS,228.01,90,,,fee schedule,Pays 90% Medicare OPPS,339.3,58,,,percent of total billed charges,58% of total billed charges,119.16,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,256.79,100,,,fee schedule,Pays 100% Medicare OPPS,333.83,130,,,fee schedule,Pays 130% Medicare OPPS,497.25,85,,,percent of total billed charges,85% of total billed charges,253.35,100,,,fee schedule,Pays 100% Medicare OPPS,119.16,526.5,
"Debridement (for example, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps)",5097597,CDM,420,RC,97597,HCPCS,Outpatient,,,585,468,,497.25,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,119.16,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,330.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,330.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,330.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,330.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,164.53,102,,,fee schedule,Pays 102% Medicare OPPS,526.5,90,,,percent of total billed charges,90% of total billed charges,204.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,401.9,68.7,,,percent of total billed charges,68.7% of total billed charges,468,80,,,percent of total billed charges,80 percent of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,145.18,90,,,fee schedule,Pays 90% Medicare OPPS,339.3,58,,,percent of total billed charges,58% of total billed charges,119.16,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.83,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,497.25,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,119.16,526.5,
PULMONARY STRESS TEST SIMPLE 6 MIN WALK,5594620,CDM,460,RC,94618,HCPCS,Outpatient,,,585,468,,497.25,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,119.16,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,330.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,330.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,330.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,330.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,526.5,90,,,percent of total billed charges,90% of total billed charges,204.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,401.9,68.7,,,percent of total billed charges,68.7% of total billed charges,468,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,339.3,58,,,percent of total billed charges,58% of total billed charges,119.16,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,497.25,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,526.5,
"Psychotherapy, 45 min",9090834,CDM,900,RC,90834,HCPCS,Outpatient,,,585,468,,497.25,85,,,percent of total billed charges,85% of total billed charges,120.19,100,,,fee schedule,Pays 100% Medicare OPPS,120.19,100,,,fee schedule,Pays 100% Medicare OPPS,120.19,100,,,fee schedule,Pays 100% Medicare OPPS,166.6,130,,,fee schedule,Pays 130% Medicare OPPS,119.16,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,330.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,330.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,330.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,330.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,122.59,102,,,fee schedule,Pays 102% Medicare OPPS,526.5,90,,,percent of total billed charges,90% of total billed charges,204.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,401.9,68.7,,,percent of total billed charges,68.7% of total billed charges,468,80,,,percent of total billed charges,80 percent of total billed charges,120.19,100,,,fee schedule,Pays 100% Medicare OPPS,108.17,90,,,fee schedule,Pays 90% Medicare OPPS,339.3,58,,,percent of total billed charges,58% of total billed charges,119.16,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,128.13,100,,,fee schedule,Pays 100% Medicare OPPS,166.6,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,120.19,100,,,fee schedule,Pays 100% Medicare OPPS,108.17,526.5,
"Psychotherapy, 60 min",9090837,CDM,900,RC,90837,HCPCS,Outpatient,,,585,468,,497.25,85,,,percent of total billed charges,85% of total billed charges,120.19,100,,,fee schedule,Pays 100% Medicare OPPS,120.19,100,,,fee schedule,Pays 100% Medicare OPPS,120.19,100,,,fee schedule,Pays 100% Medicare OPPS,166.6,130,,,fee schedule,Pays 130% Medicare OPPS,119.16,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,330.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,330.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,330.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,330.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,122.59,102,,,fee schedule,Pays 102% Medicare OPPS,526.5,90,,,percent of total billed charges,90% of total billed charges,204.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,401.9,68.7,,,percent of total billed charges,68.7% of total billed charges,468,80,,,percent of total billed charges,80 percent of total billed charges,120.19,100,,,fee schedule,Pays 100% Medicare OPPS,108.17,90,,,fee schedule,Pays 90% Medicare OPPS,339.3,58,,,percent of total billed charges,58% of total billed charges,119.16,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,128.13,100,,,fee schedule,Pays 100% Medicare OPPS,166.6,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,120.19,100,,,fee schedule,Pays 100% Medicare OPPS,108.17,526.5,
PREMARIN (ESTROGEN CONJ) VAG CRM 0.625MG,2605149,CDM,637,RC,,,Outpatient,,,590,472,,501.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,120.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,531,90,,,percent of total billed charges,90% of total billed charges,206.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,405.33,68.7,,,percent of total billed charges,68.7% of total billed charges,472,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,342.2,58,,,percent of total billed charges,58% of total billed charges,120.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,501.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,120.18,531,
PROZAC (FLUOXETINE),3000244,CDM,301,RC,80299,HCPCS,Outpatient,,,590,472,,501.5,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.01,102,,,fee schedule,Pays 102% Medicare OPPS,531,90,,,percent of total billed charges,90% of total billed charges,18.95,125.18,,,fee schedule,125.18% of custom fee schedule,405.33,68.7,,,percent of total billed charges,68.7% of total billed charges,472,80,,,percent of total billed charges,80 percent of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,90,,,fee schedule,Pays 90% Medicare OPPS,342.2,58,,,percent of total billed charges,58% of total billed charges,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,501.5,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,531,
3RD AMINOLEVULINIC ACID,3082135,CDM,301,RC,82135,HCPCS,Outpatient,,,590,472,,501.5,85,,,percent of total billed charges,85% of total billed charges,16.45,100,,,fee schedule,Pays 100% Medicare OPPS,16.45,100,,,fee schedule,Pays 100% Medicare OPPS,16.45,100,,,fee schedule,Pays 100% Medicare OPPS,21.38,130,,,fee schedule,Pays 130% Medicare OPPS,24.92,120.37,,,fee schedule,120.37% of custom fee schedule,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.77,102,,,fee schedule,Pays 102% Medicare OPPS,531,90,,,percent of total billed charges,90% of total billed charges,25.91,125.18,,,fee schedule,125.18% of custom fee schedule,405.33,68.7,,,percent of total billed charges,68.7% of total billed charges,472,80,,,percent of total billed charges,80 percent of total billed charges,16.45,100,,,fee schedule,Pays 100% Medicare OPPS,14.8,90,,,fee schedule,Pays 90% Medicare OPPS,342.2,58,,,percent of total billed charges,58% of total billed charges,24.92,120.37,,,fee schedule,120.37% of custom fee schedule,16.45,100,,,fee schedule,Pays 100% Medicare OPPS,21.38,130,,,fee schedule,Pays 130% Medicare OPPS,501.5,85,,,percent of total billed charges,85% of total billed charges,16.45,100,,,fee schedule,Pays 100% Medicare OPPS,14.8,531,
"DIURETIC PANEL, URINE",3082492,CDM,301,RC,82775,HCPCS,Outpatient,,,590,472,,501.5,85,,,percent of total billed charges,85% of total billed charges,21.07,100,,,fee schedule,Pays 100% Medicare OPPS,21.07,100,,,fee schedule,Pays 100% Medicare OPPS,21.07,100,,,fee schedule,Pays 100% Medicare OPPS,27.39,130,,,fee schedule,Pays 130% Medicare OPPS,31.89,120.37,,,fee schedule,120.37% of custom fee schedule,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,21.49,102,,,fee schedule,Pays 102% Medicare OPPS,531,90,,,percent of total billed charges,90% of total billed charges,33.16,125.18,,,fee schedule,125.18% of custom fee schedule,405.33,68.7,,,percent of total billed charges,68.7% of total billed charges,472,80,,,percent of total billed charges,80 percent of total billed charges,21.07,100,,,fee schedule,Pays 100% Medicare OPPS,18.96,90,,,fee schedule,Pays 90% Medicare OPPS,342.2,58,,,percent of total billed charges,58% of total billed charges,31.89,120.37,,,fee schedule,120.37% of custom fee schedule,21.07,100,,,fee schedule,Pays 100% Medicare OPPS,27.39,130,,,fee schedule,Pays 130% Medicare OPPS,501.5,85,,,percent of total billed charges,85% of total billed charges,21.07,100,,,fee schedule,Pays 100% Medicare OPPS,18.96,531,
PARATHYROID HORMONE (PTH),3083970,CDM,301,RC,83970,HCPCS,Outpatient,,,590,472,,501.5,85,,,percent of total billed charges,85% of total billed charges,41.28,100,,,fee schedule,Pays 100% Medicare OPPS,41.28,100,,,fee schedule,Pays 100% Medicare OPPS,41.28,100,,,fee schedule,Pays 100% Medicare OPPS,53.66,130,,,fee schedule,Pays 130% Medicare OPPS,62.47,120.37,,,fee schedule,120.37% of custom fee schedule,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,42.1,102,,,fee schedule,Pays 102% Medicare OPPS,531,90,,,percent of total billed charges,90% of total billed charges,64.97,125.18,,,fee schedule,125.18% of custom fee schedule,405.33,68.7,,,percent of total billed charges,68.7% of total billed charges,472,80,,,percent of total billed charges,80 percent of total billed charges,41.28,100,,,fee schedule,Pays 100% Medicare OPPS,37.15,90,,,fee schedule,Pays 90% Medicare OPPS,342.2,58,,,percent of total billed charges,58% of total billed charges,62.47,120.37,,,fee schedule,120.37% of custom fee schedule,41.28,100,,,fee schedule,Pays 100% Medicare OPPS,53.66,130,,,fee schedule,Pays 130% Medicare OPPS,501.5,85,,,percent of total billed charges,85% of total billed charges,41.28,100,,,fee schedule,Pays 100% Medicare OPPS,37.15,531,
BACTERIAL ANTIGENS PANEL,3086403,CDM,302,RC,,,Outpatient,,,590,472,,501.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,120.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,531,90,,,percent of total billed charges,90% of total billed charges,206.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,405.33,68.7,,,percent of total billed charges,68.7% of total billed charges,472,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,342.2,58,,,percent of total billed charges,58% of total billed charges,120.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,501.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,120.18,531,
3RD STREP PNEUMOCOCCAL 14 PANEL,3086609,CDM,300,RC,86609,HCPCS,Outpatient,,,590,472,,501.5,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,333.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.13,102,,,fee schedule,Pays 102% Medicare OPPS,531,90,,,percent of total billed charges,90% of total billed charges,20.28,125.18,,,fee schedule,125.18% of custom fee schedule,405.33,68.7,,,percent of total billed charges,68.7% of total billed charges,472,80,,,percent of total billed charges,80 percent of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,90,,,fee schedule,Pays 90% Medicare OPPS,342.2,58,,,percent of total billed charges,58% of total billed charges,19.5,120.37,,,fee schedule,120.37% of custom fee schedule,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,16.74,130,,,fee schedule,Pays 130% Medicare OPPS,501.5,85,,,percent of total billed charges,85% of total billed charges,12.88,100,,,fee schedule,Pays 100% Medicare OPPS,11.59,531,
Echo without doppler study,5793307,CDM,483,RC,93307,HCPCS,Outpatient,,,590,472,,501.5,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,120.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,531,90,,,percent of total billed charges,90% of total billed charges,206.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,405.33,68.7,,,percent of total billed charges,68.7% of total billed charges,472,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,342.2,58,,,percent of total billed charges,58% of total billed charges,120.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,501.5,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,120.18,986.63,
SINUS IRRIGATION CATHETER 22CM,1570756,CDM,272,RC,,,Outpatient,,,595,476,,505.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,121.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,336.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,336.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,336.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,336.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,535.5,90,,,percent of total billed charges,90% of total billed charges,208.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,408.77,68.7,,,percent of total billed charges,68.7% of total billed charges,476,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,345.1,58,,,percent of total billed charges,58% of total billed charges,121.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,505.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,121.2,535.5,
"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities",2012000,CDM,450,RC,12001,HCPCS,Outpatient,,,595,476,,505.75,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,121.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,336.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,336.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,336.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,336.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,164.54,102,,,fee schedule,Pays 102% Medicare OPPS,535.5,90,,,percent of total billed charges,90% of total billed charges,208.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,408.77,68.7,,,percent of total billed charges,68.7% of total billed charges,476,80,,,percent of total billed charges,80 percent of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,145.18,90,,,fee schedule,Pays 90% Medicare OPPS,345.1,58,,,percent of total billed charges,58% of total billed charges,121.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.83,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,505.75,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,121.2,535.5,
FACIAL LAC SIMPLE <2.5CM,2012011,CDM,450,RC,,,Outpatient,,,595,476,,505.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,121.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,336.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,336.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,336.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,336.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,535.5,90,,,percent of total billed charges,90% of total billed charges,208.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,408.77,68.7,,,percent of total billed charges,68.7% of total billed charges,476,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,345.1,58,,,percent of total billed charges,58% of total billed charges,121.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,505.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,121.2,535.5,
INITIAL HOSP CARE DAY 50 MIN,2099222,CDM,960,RC,99222,HCPCS,Outpatient,,,595,476,,,,,,other,Not Applicable,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not Applicable,,,,,other,Not Applicable,,,,,other,Not Applicable,,,,,other,Not reimbursable per contract,,,,,other,Not Applicable,,,,,other,Not Applicable,,,,,other,Not Applicable,,,,,other,Not Applicable,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not Applicable,,,,,other,Not Applicable,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not Applicable,,,,,other,Not reimbursable per contract,,,No Contract for Physician
"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",4300204,CDM,401,RC,77065,HCPCS,Outpatient,,,595,476,,505.75,85,,,percent of total billed charges,85% of total billed charges,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,101.74,130,,,fee schedule,Pays 130% Medicare OPPS,121.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,336.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,336.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,336.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,334.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,81.2,102,,,fee schedule,Pays 102% Medicare OPPS,535.5,90,,,percent of total billed charges,90% of total billed charges,208.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,408.77,68.7,,,percent of total billed charges,68.7% of total billed charges,476,80,,,percent of total billed charges,80 percent of total billed charges,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,71.65,90,,,fee schedule,Pays 90% Medicare OPPS,345.1,58,,,percent of total billed charges,58% of total billed charges,121.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,78.26,100,,,fee schedule,Pays 100% Medicare OPPS,101.74,130,,,fee schedule,Pays 130% Medicare OPPS,505.75,85,,,percent of total billed charges,85% of total billed charges,79.61,100,,,fee schedule,Pays 100% Medicare OPPS,71.65,535.5,
Shaving of shoulder bone using an endoscope,1529826,CDM,360,RC,29826,HCPCS,Outpatient,,,600,480,,510,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,122.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,,,,,other,Not reimbursable per contract,540,90,,,percent of total billed charges,90% of total billed charges,210,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,412.2,68.7,,,percent of total billed charges,68.7% of total billed charges,480,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,348,58,,,percent of total billed charges,58% of total billed charges,122.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,510,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,122.22,986.63,
WAND COBLATION,1570770,CDM,272,RC,,,Outpatient,,,600,480,,510,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,122.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,339,56.5,,,percent of total billed charges,56.5 percent of total billed charges,339,56.5,,,percent of total billed charges,56.5 percent of total billed charges,339,56.5,,,percent of total billed charges,56.5 percent of total billed charges,339,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,540,90,,,percent of total billed charges,90% of total billed charges,210,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,412.2,68.7,,,percent of total billed charges,68.7% of total billed charges,480,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,348,58,,,percent of total billed charges,58% of total billed charges,122.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,510,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,122.22,540,
LAC INTRM HAND/FEET <2.5 OR LESS,2012041,CDM,450,RC,12041,HCPCS,Outpatient,,,610,488,,518.5,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,124.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,344.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,344.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,344.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,344.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,316.7,102,,,fee schedule,Pays 102% Medicare OPPS,549,90,,,percent of total billed charges,90% of total billed charges,213.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,419.07,68.7,,,percent of total billed charges,68.7% of total billed charges,488,80,,,percent of total billed charges,80 percent of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,279.44,90,,,fee schedule,Pays 90% Medicare OPPS,353.8,58,,,percent of total billed charges,58% of total billed charges,124.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,328.14,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,518.5,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,124.26,549,
ALBUMIN HUMAN 25% IV : 100ML (25GM),2610016,CDM,250,RC,,,Outpatient,,,610,488,,518.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,124.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,344.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,344.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,344.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,344.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,549,90,,,percent of total billed charges,90% of total billed charges,213.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,419.07,68.7,,,percent of total billed charges,68.7% of total billed charges,488,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,353.8,58,,,percent of total billed charges,58% of total billed charges,124.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,518.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,124.26,549,
"ARSENIC, other",3083015,CDM,301,RC,82175,HCPCS,Outpatient,,,610,488,,518.5,85,,,percent of total billed charges,85% of total billed charges,18.97,100,,,fee schedule,Pays 100% Medicare OPPS,18.97,100,,,fee schedule,Pays 100% Medicare OPPS,18.97,100,,,fee schedule,Pays 100% Medicare OPPS,24.66,130,,,fee schedule,Pays 130% Medicare OPPS,28.72,120.37,,,fee schedule,120.37% of custom fee schedule,344.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,344.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,344.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,344.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.34,102,,,fee schedule,Pays 102% Medicare OPPS,549,90,,,percent of total billed charges,90% of total billed charges,29.87,125.18,,,fee schedule,125.18% of custom fee schedule,419.07,68.7,,,percent of total billed charges,68.7% of total billed charges,488,80,,,percent of total billed charges,80 percent of total billed charges,18.97,100,,,fee schedule,Pays 100% Medicare OPPS,17.07,90,,,fee schedule,Pays 90% Medicare OPPS,353.8,58,,,percent of total billed charges,58% of total billed charges,28.72,120.37,,,fee schedule,120.37% of custom fee schedule,18.97,100,,,fee schedule,Pays 100% Medicare OPPS,24.66,130,,,fee schedule,Pays 130% Medicare OPPS,518.5,85,,,percent of total billed charges,85% of total billed charges,18.97,100,,,fee schedule,Pays 100% Medicare OPPS,17.07,549,
IMPLANT FH TOE,7905530,CDM,270,RC,,,Outpatient,,,610,488,,518.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,124.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,344.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,344.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,344.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,344.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,549,90,,,percent of total billed charges,90% of total billed charges,213.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,419.07,68.7,,,percent of total billed charges,68.7% of total billed charges,488,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,353.8,58,,,percent of total billed charges,58% of total billed charges,124.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,518.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,124.26,549,
IV HYDRATION INITIAL,1090760,CDM,760,RC,96360,HCPCS,Outpatient,,,615,492,,522.75,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,125.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,187.43,102,,,fee schedule,Pays 102% Medicare OPPS,553.5,90,,,percent of total billed charges,90% of total billed charges,215.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,422.51,68.7,,,percent of total billed charges,68.7% of total billed charges,492,80,,,percent of total billed charges,80 percent of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,165.38,90,,,fee schedule,Pays 90% Medicare OPPS,356.7,58,,,percent of total billed charges,58% of total billed charges,125.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,181.69,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,522.75,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,125.28,553.5,
OR ACUITY LEVEL II X 15 MIN,1501152,CDM,360,RC,,,Outpatient,,,615,492,,522.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,125.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,553.5,90,,,percent of total billed charges,90% of total billed charges,215.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,422.51,68.7,,,percent of total billed charges,68.7% of total billed charges,492,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,356.7,58,,,percent of total billed charges,58% of total billed charges,125.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,522.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,125.28,553.5,
IV HYDRATION INITIAL,1590760,CDM,760,RC,96360,HCPCS,Outpatient,,,615,492,,522.75,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,125.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,187.43,102,,,fee schedule,Pays 102% Medicare OPPS,553.5,90,,,percent of total billed charges,90% of total billed charges,215.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,422.51,68.7,,,percent of total billed charges,68.7% of total billed charges,492,80,,,percent of total billed charges,80 percent of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,165.38,90,,,fee schedule,Pays 90% Medicare OPPS,356.7,58,,,percent of total billed charges,58% of total billed charges,125.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,181.69,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,522.75,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,125.28,553.5,
IV HYDRATION INITIAL,2090760,CDM,450,RC,96360,HCPCS,Outpatient,,,615,492,,522.75,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,125.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,187.43,102,,,fee schedule,Pays 102% Medicare OPPS,553.5,90,,,percent of total billed charges,90% of total billed charges,215.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,422.51,68.7,,,percent of total billed charges,68.7% of total billed charges,492,80,,,percent of total billed charges,80 percent of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,165.38,90,,,fee schedule,Pays 90% Medicare OPPS,356.7,58,,,percent of total billed charges,58% of total billed charges,125.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,181.69,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,522.75,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,125.28,553.5,
SQUAMOUS CA ANTIGEN (SCA),3086316,CDM,302,RC,86316,HCPCS,Outpatient,,,615,492,,522.75,85,,,percent of total billed charges,85% of total billed charges,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,27.05,130,,,fee schedule,Pays 130% Medicare OPPS,31.49,120.37,,,fee schedule,120.37% of custom fee schedule,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,21.22,102,,,fee schedule,Pays 102% Medicare OPPS,553.5,90,,,percent of total billed charges,90% of total billed charges,32.75,125.18,,,fee schedule,125.18% of custom fee schedule,422.51,68.7,,,percent of total billed charges,68.7% of total billed charges,492,80,,,percent of total billed charges,80 percent of total billed charges,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,18.72,90,,,fee schedule,Pays 90% Medicare OPPS,356.7,58,,,percent of total billed charges,58% of total billed charges,31.49,120.37,,,fee schedule,120.37% of custom fee schedule,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,27.05,130,,,fee schedule,Pays 130% Medicare OPPS,522.75,85,,,percent of total billed charges,85% of total billed charges,20.81,100,,,fee schedule,Pays 100% Medicare OPPS,18.72,553.5,
ARTHROGRAM TRAY,4000800,CDM,270,RC,,,Outpatient,,,615,492,,522.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,125.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,553.5,90,,,percent of total billed charges,90% of total billed charges,215.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,422.51,68.7,,,percent of total billed charges,68.7% of total billed charges,492,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,356.7,58,,,percent of total billed charges,58% of total billed charges,125.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,522.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,125.28,553.5,
IV HYDRATION INITIAL,4090760,CDM,760,RC,96360,HCPCS,Outpatient,,,615,492,,522.75,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,125.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,187.43,102,,,fee schedule,Pays 102% Medicare OPPS,553.5,90,,,percent of total billed charges,90% of total billed charges,215.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,422.51,68.7,,,percent of total billed charges,68.7% of total billed charges,492,80,,,percent of total billed charges,80 percent of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,165.38,90,,,fee schedule,Pays 90% Medicare OPPS,356.7,58,,,percent of total billed charges,58% of total billed charges,125.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,181.69,100,,,fee schedule,Pays 100% Medicare OPPS,236.2,130,,,fee schedule,Pays 130% Medicare OPPS,522.75,85,,,percent of total billed charges,85% of total billed charges,183.77,100,,,fee schedule,Pays 100% Medicare OPPS,125.28,553.5,
GASTROSTOMY TUBE 000287,7950209,CDM,270,RC,,,Outpatient,,,615,492,,522.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,125.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,347.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,553.5,90,,,percent of total billed charges,90% of total billed charges,215.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,422.51,68.7,,,percent of total billed charges,68.7% of total billed charges,492,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,356.7,58,,,percent of total billed charges,58% of total billed charges,125.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,522.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,125.28,553.5,
PULMICORT (BUDESONIDE) FLEXHALER 90MCG,2610141,CDM,636,RC,,,Both,,,617.65,494.12,,525,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,125.82,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,322.23,52.17,,,case rate,100% of BCBS case rate,322.23,52.17,,,case rate,100% of BCBS case rate,322.23,52.17,,,case rate,100% of BCBS case rate,322.23,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,555.89,90,,,percent of total billed charges,90% of total billed charges,216.18,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,424.33,68.7,,,percent of total billed charges,68.7% of total billed charges,494.12,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,358.24,58,,,percent of total billed charges,58% of total billed charges,125.82,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,525,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,125.82,555.89,
TRIGGER POINTS INJ,2020551,CDM,450,RC,,,Outpatient,,,620,496,,527,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,126.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,350.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,350.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,350.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,350.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,558,90,,,percent of total billed charges,90% of total billed charges,217,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,425.94,68.7,,,percent of total billed charges,68.7% of total billed charges,496,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,359.6,58,,,percent of total billed charges,58% of total billed charges,126.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,527,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,126.29,558,
Draining or injecting medication into a small joint/bursa without ultrasound,2020600,CDM,450,RC,20600,HCPCS,Outpatient,,,620,496,,527,85,,,percent of total billed charges,85% of total billed charges,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,310.88,130,,,fee schedule,Pays 130% Medicare OPPS,126.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,350.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,350.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,350.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,350.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,239.38,102,,,fee schedule,Pays 102% Medicare OPPS,558,90,,,percent of total billed charges,90% of total billed charges,217,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,425.94,68.7,,,percent of total billed charges,68.7% of total billed charges,496,80,,,percent of total billed charges,80 percent of total billed charges,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,211.22,90,,,fee schedule,Pays 90% Medicare OPPS,359.6,58,,,percent of total billed charges,58% of total billed charges,126.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,239.14,100,,,fee schedule,Pays 100% Medicare OPPS,310.88,130,,,fee schedule,Pays 130% Medicare OPPS,527,85,,,percent of total billed charges,85% of total billed charges,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,126.29,558,
DO NOT USE,2027625,CDM,450,RC,,,Outpatient,,,620,496,,527,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,126.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,350.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,350.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,350.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,350.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,558,90,,,percent of total billed charges,90% of total billed charges,217,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,425.94,68.7,,,percent of total billed charges,68.7% of total billed charges,496,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,359.6,58,,,percent of total billed charges,58% of total billed charges,126.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,527,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,126.29,558,
CORTROSYN (COSYNTROPIN) INJ 0.25MG,2601422,CDM,636,RC,J0833,HCPCS,Both,,,620,496,,527,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,126.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,323.46,52.17,,,case rate,100% of BCBS case rate,323.46,52.17,,,case rate,100% of BCBS case rate,323.46,52.17,,,case rate,100% of BCBS case rate,323.46,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,558,90,,,percent of total billed charges,90% of total billed charges,217,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,425.94,68.7,,,percent of total billed charges,68.7% of total billed charges,496,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,359.6,58,,,percent of total billed charges,58% of total billed charges,126.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,527,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,126.29,558,
3RD BORDETELLA PERTUSSIN IGG &IGA ABS,3086615,CDM,301,RC,83520,HCPCS,Outpatient,,,620,496,,527,85,,,percent of total billed charges,85% of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,130,APC,,fee schedule,Pays 130% Medicare OPPS,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,350.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,350.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,350.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,350.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.61,102,,,fee schedule,Pays 102% Medicare OPPS,558,90,,,percent of total billed charges,90% of total billed charges,20.38,125.18,,,fee schedule,125.18% of custom fee schedule,425.94,68.7,,,percent of total billed charges,68.7% of total billed charges,496,80,,,percent of total billed charges,80 percent of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,15.54,90,,,fee schedule,Pays 90% Medicare OPPS,359.6,58,,,percent of total billed charges,58% of total billed charges,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,130,APC,,fee schedule,Pays 130% Medicare OPPS,527,85,,,percent of total billed charges,85% of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,15.54,558,
Serial radiologic examination of the abdomen,4007402,CDM,320,RC,74022,HCPCS,Outpatient,,,620,496,,527,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,126.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,350.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,350.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,350.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,348.44,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,558,90,,,percent of total billed charges,90% of total billed charges,217,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,425.94,68.7,,,percent of total billed charges,68.7% of total billed charges,496,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,359.6,58,,,percent of total billed charges,58% of total billed charges,126.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,527,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,558,
Serial radiologic examination of the abdomen,4074022,CDM,320,RC,74022,HCPCS,Outpatient,,,620,496,,527,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,126.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,350.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,350.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,350.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,348.44,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,558,90,,,percent of total billed charges,90% of total billed charges,217,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,425.94,68.7,,,percent of total billed charges,68.7% of total billed charges,496,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,359.6,58,,,percent of total billed charges,58% of total billed charges,126.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,527,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,558,
TROCAR BLADELESS 35NLT,7950261,CDM,270,RC,,,Outpatient,,,620,496,,527,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,126.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,350.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,350.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,350.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,350.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,558,90,,,percent of total billed charges,90% of total billed charges,217,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,425.94,68.7,,,percent of total billed charges,68.7% of total billed charges,496,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,359.6,58,,,percent of total billed charges,58% of total billed charges,126.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,527,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,126.29,558,
Separation and removal of the entire nail plate or a portion of nail plate,2011730,CDM,450,RC,11730,HCPCS,Outpatient,,,625,500,,531.25,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,127.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,353.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,353.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,353.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,353.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,164.54,102,,,fee schedule,Pays 102% Medicare OPPS,562.5,90,,,percent of total billed charges,90% of total billed charges,218.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,429.38,68.7,,,percent of total billed charges,68.7% of total billed charges,500,80,,,percent of total billed charges,80 percent of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,145.18,90,,,fee schedule,Pays 90% Medicare OPPS,362.5,58,,,percent of total billed charges,58% of total billed charges,127.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.83,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,531.25,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,127.31,562.5,
EXTRACTOR PRO RX RETRIEVAL BALLOON 9-12,1750041,CDM,272,RC,,,Outpatient,,,635,508,,539.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,129.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,571.5,90,,,percent of total billed charges,90% of total billed charges,222.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,436.25,68.7,,,percent of total billed charges,68.7% of total billed charges,508,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,368.3,58,,,percent of total billed charges,58% of total billed charges,129.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,539.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,129.35,571.5,
EXTRACTOR PRO RX RETRIEVAL BALLOON 12-15,1750042,CDM,272,RC,,,Outpatient,,,635,508,,539.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,129.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,571.5,90,,,percent of total billed charges,90% of total billed charges,222.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,436.25,68.7,,,percent of total billed charges,68.7% of total billed charges,508,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,368.3,58,,,percent of total billed charges,58% of total billed charges,129.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,539.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,129.35,571.5,
EXTRACTOR PRO RX RETRIEVAL BALLOON 15-18,1750043,CDM,272,RC,,,Outpatient,,,635,508,,539.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,129.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,571.5,90,,,percent of total billed charges,90% of total billed charges,222.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,436.25,68.7,,,percent of total billed charges,68.7% of total billed charges,508,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,368.3,58,,,percent of total billed charges,58% of total billed charges,129.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,539.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,129.35,571.5,
FACIAL LAC SIMPLE 5.1-7.5,2012014,CDM,450,RC,12014,HCPCS,Outpatient,,,635,508,,539.75,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,129.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,164.54,102,,,fee schedule,Pays 102% Medicare OPPS,571.5,90,,,percent of total billed charges,90% of total billed charges,222.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,436.25,68.7,,,percent of total billed charges,68.7% of total billed charges,508,80,,,percent of total billed charges,80 percent of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,145.18,90,,,fee schedule,Pays 90% Medicare OPPS,368.3,58,,,percent of total billed charges,58% of total billed charges,129.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.83,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,539.75,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,129.35,571.5,
LAC INTRM 2.6-7.5CM,2012032,CDM,450,RC,,,Outpatient,,,635,508,,539.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,129.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,571.5,90,,,percent of total billed charges,90% of total billed charges,222.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,436.25,68.7,,,percent of total billed charges,68.7% of total billed charges,508,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,368.3,58,,,percent of total billed charges,58% of total billed charges,129.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,539.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,129.35,571.5,
LAC INTRM 2.6-7.5CM,2012042,CDM,450,RC,,,Outpatient,,,635,508,,539.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,129.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,571.5,90,,,percent of total billed charges,90% of total billed charges,222.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,436.25,68.7,,,percent of total billed charges,68.7% of total billed charges,508,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,368.3,58,,,percent of total billed charges,58% of total billed charges,129.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,539.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,129.35,571.5,
NEXSTAT TOPICAL POWDER,2600182,CDM,250,RC,,,Outpatient,,,635,508,,539.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,129.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,571.5,90,,,percent of total billed charges,90% of total billed charges,222.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,436.25,68.7,,,percent of total billed charges,68.7% of total billed charges,508,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,368.3,58,,,percent of total billed charges,58% of total billed charges,129.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,539.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,129.35,571.5,
PROPOXYPHENE (DARVON) LEVEL,3000239,CDM,301,RC,80367,HCPCS,Outpatient,,,635,508,,539.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,129.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,571.5,90,,,percent of total billed charges,90% of total billed charges,222.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,436.25,68.7,,,percent of total billed charges,68.7% of total billed charges,508,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,368.3,58,,,percent of total billed charges,58% of total billed charges,129.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,539.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,129.35,571.5,
"SEROTONIN, WHOLE BLOOD",3000280,CDM,301,RC,84260,HCPCS,Outpatient,,,635,508,,539.75,85,,,percent of total billed charges,85% of total billed charges,30.98,100,,,fee schedule,Pays 100% Medicare OPPS,30.98,100,,,fee schedule,Pays 100% Medicare OPPS,30.98,100,,,fee schedule,Pays 100% Medicare OPPS,40.27,130,,,fee schedule,Pays 130% Medicare OPPS,46.88,120.37,,,fee schedule,120.37% of custom fee schedule,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.59,102,,,fee schedule,Pays 102% Medicare OPPS,571.5,90,,,percent of total billed charges,90% of total billed charges,48.76,125.18,,,fee schedule,125.18% of custom fee schedule,436.25,68.7,,,percent of total billed charges,68.7% of total billed charges,508,80,,,percent of total billed charges,80 percent of total billed charges,30.98,100,,,fee schedule,Pays 100% Medicare OPPS,27.88,90,,,fee schedule,Pays 90% Medicare OPPS,368.3,58,,,percent of total billed charges,58% of total billed charges,46.88,120.37,,,fee schedule,120.37% of custom fee schedule,30.98,100,,,fee schedule,Pays 100% Medicare OPPS,40.27,130,,,fee schedule,Pays 130% Medicare OPPS,539.75,85,,,percent of total billed charges,85% of total billed charges,30.98,100,,,fee schedule,Pays 100% Medicare OPPS,27.88,571.5,
ZYPREXA LEVEL,3000340,CDM,301,RC,80342,HCPCS,Outpatient,,,635,508,,539.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,23.57,120.37,,,fee schedule,120.37% of custom fee schedule,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,571.5,90,,,percent of total billed charges,90% of total billed charges,24.51,125.18,,,fee schedule,125.18% of custom fee schedule,436.25,68.7,,,percent of total billed charges,68.7% of total billed charges,508,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,368.3,58,,,percent of total billed charges,58% of total billed charges,23.57,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,539.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,23.57,571.5,
"SEROTONIN, SERUM",3084260,CDM,301,RC,84260,HCPCS,Outpatient,,,635,508,,539.75,85,,,percent of total billed charges,85% of total billed charges,30.98,100,,,fee schedule,Pays 100% Medicare OPPS,30.98,100,,,fee schedule,Pays 100% Medicare OPPS,30.98,100,,,fee schedule,Pays 100% Medicare OPPS,40.27,130,,,fee schedule,Pays 130% Medicare OPPS,46.88,120.37,,,fee schedule,120.37% of custom fee schedule,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,31.59,102,,,fee schedule,Pays 102% Medicare OPPS,571.5,90,,,percent of total billed charges,90% of total billed charges,48.76,125.18,,,fee schedule,125.18% of custom fee schedule,436.25,68.7,,,percent of total billed charges,68.7% of total billed charges,508,80,,,percent of total billed charges,80 percent of total billed charges,30.98,100,,,fee schedule,Pays 100% Medicare OPPS,27.88,90,,,fee schedule,Pays 90% Medicare OPPS,368.3,58,,,percent of total billed charges,58% of total billed charges,46.88,120.37,,,fee schedule,120.37% of custom fee schedule,30.98,100,,,fee schedule,Pays 100% Medicare OPPS,40.27,130,,,fee schedule,Pays 130% Medicare OPPS,539.75,85,,,percent of total billed charges,85% of total billed charges,30.98,100,,,fee schedule,Pays 100% Medicare OPPS,27.88,571.5,
3RD CMV QUANTATIVE BY PCR,3087497,CDM,302,RC,87497,HCPCS,Outpatient,,,635,508,,539.75,85,,,percent of total billed charges,85% of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,130,APC,,fee schedule,Pays 130% Medicare OPPS,64.84,120.37,,,fee schedule,120.37% of custom fee schedule,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,43.69,102,,,fee schedule,Pays 102% Medicare OPPS,571.5,90,,,percent of total billed charges,90% of total billed charges,67.43,125.18,,,fee schedule,125.18% of custom fee schedule,436.25,68.7,,,percent of total billed charges,68.7% of total billed charges,508,80,,,percent of total billed charges,80 percent of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,38.55,90,,,fee schedule,Pays 90% Medicare OPPS,368.3,58,,,percent of total billed charges,58% of total billed charges,64.84,120.37,,,fee schedule,120.37% of custom fee schedule,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,130,APC,,fee schedule,Pays 130% Medicare OPPS,539.75,85,,,percent of total billed charges,85% of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,38.55,571.5,
Limited ultrasound of the breast,4600003,CDM,402,RC,76642,HCPCS,Outpatient,,,635,508,,539.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,129.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,356.87,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,571.5,90,,,percent of total billed charges,90% of total billed charges,222.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,436.25,68.7,,,percent of total billed charges,68.7% of total billed charges,508,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,368.3,58,,,percent of total billed charges,58% of total billed charges,129.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,539.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,571.5,
Limited ultrasound of the breast,4676645,CDM,402,RC,76642,HCPCS,Outpatient,,,635,508,,539.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,129.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,356.87,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,571.5,90,,,percent of total billed charges,90% of total billed charges,222.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,436.25,68.7,,,percent of total billed charges,68.7% of total billed charges,508,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,368.3,58,,,percent of total billed charges,58% of total billed charges,129.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,539.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,571.5,
IRIS RETRACTOR,7950196,CDM,270,RC,,,Outpatient,,,635,508,,539.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,129.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,358.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,571.5,90,,,percent of total billed charges,90% of total billed charges,222.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,436.25,68.7,,,percent of total billed charges,68.7% of total billed charges,508,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,368.3,58,,,percent of total billed charges,58% of total billed charges,129.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,539.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,129.35,571.5,
DRILL BIT 2.7 MM THREE FLUTED QC 125 MM,1570027,CDM,278,RC,A4649,HCPCS,Both,,,640,512,,544,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,130.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,576,90,,,percent of total billed charges,90% of total billed charges,224,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,439.68,68.7,,,percent of total billed charges,68.7% of total billed charges,512,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,371.2,58,,,percent of total billed charges,58% of total billed charges,130.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,544,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,576,
SINUS BLADE SUCTION SHAVER,1570745,CDM,272,RC,,,Outpatient,,,640,512,,544,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,130.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,361.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,361.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,361.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,361.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,576,90,,,percent of total billed charges,90% of total billed charges,224,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,439.68,68.7,,,percent of total billed charges,68.7% of total billed charges,512,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,371.2,58,,,percent of total billed charges,58% of total billed charges,130.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,544,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,130.37,576,
GOLD PROBE 6007,1750002,CDM,272,RC,,,Outpatient,,,640,512,,544,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,130.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,361.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,361.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,361.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,361.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,576,90,,,percent of total billed charges,90% of total billed charges,224,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,439.68,68.7,,,percent of total billed charges,68.7% of total billed charges,512,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,371.2,58,,,percent of total billed charges,58% of total billed charges,130.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,544,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,130.37,576,
DISLOC JAW TX,2021480,CDM,450,RC,21480,HCPCS,Outpatient,,,640,512,,544,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,130.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,361.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,361.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,361.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,361.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,188.85,102,,,fee schedule,Pays 102% Medicare OPPS,576,90,,,percent of total billed charges,90% of total billed charges,224,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,439.68,68.7,,,percent of total billed charges,68.7% of total billed charges,512,80,,,percent of total billed charges,80 percent of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,166.63,90,,,fee schedule,Pays 90% Medicare OPPS,371.2,58,,,percent of total billed charges,58% of total billed charges,130.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,182.08,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,544,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,130.37,576,
INTEGRILIN (EPTIFIBATIDE) INJ 20MG,2605029,CDM,636,RC,J1327,HCPCS,Both,,,640,512,,544,85,,,percent of total billed charges,85% of total billed charges,1.87,100,,,fee schedule,Pays 100% Medicare OPPS,1.87,100,,,fee schedule,Pays 100% Medicare OPPS,1.87,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,130.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,333.89,52.17,,,case rate,100% of BCBS case rate,333.89,52.17,,,case rate,100% of BCBS case rate,333.89,52.17,,,case rate,100% of BCBS case rate,333.89,52.17,,,case rate,100% of BCBS case rate,1.9,102,,,fee schedule,Pays 102% Medicare OPPS,576,90,,,percent of total billed charges,90% of total billed charges,224,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,439.68,68.7,,,percent of total billed charges,68.7% of total billed charges,512,80,,,percent of total billed charges,80 percent of total billed charges,1.87,100,,,fee schedule,Pays 100% Medicare OPPS,1.68,90,,,fee schedule,Pays 90% Medicare OPPS,371.2,58,,,percent of total billed charges,58% of total billed charges,130.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,544,85,,,percent of total billed charges,85% of total billed charges,1.87,100,,,fee schedule,Pays 100% Medicare OPPS,1.68,576,
XR SKULL 4 VIEWS,4070260,CDM,320,RC,70260,HCPCS,Outpatient,,,640,512,,544,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,130.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,361.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,361.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,361.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,359.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,576,90,,,percent of total billed charges,90% of total billed charges,224,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,439.68,68.7,,,percent of total billed charges,68.7% of total billed charges,512,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,371.2,58,,,percent of total billed charges,58% of total billed charges,130.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,544,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,576,
HERNIA PERFIX PLUG 0112770,1570011,CDM,278,RC,C1781,HCPCS,Both,,,650,520,,552.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,132.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,585,90,,,percent of total billed charges,90% of total billed charges,227.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,446.55,68.7,,,percent of total billed charges,68.7% of total billed charges,520,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,377,58,,,percent of total billed charges,58% of total billed charges,132.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,552.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,585,
FB REMOVAL NASAL,2030300,CDM,450,RC,30300,HCPCS,Outpatient,,,650,520,,552.5,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,132.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,585,90,,,percent of total billed charges,90% of total billed charges,227.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,446.55,68.7,,,percent of total billed charges,68.7% of total billed charges,520,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,377,58,,,percent of total billed charges,58% of total billed charges,132.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,552.5,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,585,
FB REMOVAL EYE,2065205,CDM,450,RC,65205,HCPCS,Outpatient,,,650,520,,552.5,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,132.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,585,90,,,percent of total billed charges,90% of total billed charges,227.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,446.55,68.7,,,percent of total billed charges,68.7% of total billed charges,520,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,377,58,,,percent of total billed charges,58% of total billed charges,132.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,552.5,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,585,
RIBOFLAVIN (VITAMIN B-2),3000260,CDM,301,RC,84252,HCPCS,Outpatient,,,650,520,,552.5,85,,,percent of total billed charges,85% of total billed charges,20.23,100,,,fee schedule,Pays 100% Medicare OPPS,20.23,100,,,fee schedule,Pays 100% Medicare OPPS,20.23,100,,,fee schedule,Pays 100% Medicare OPPS,26.31,130,APC,,fee schedule,Pays 130% Medicare OPPS,30.63,120.37,,,fee schedule,120.37% of custom fee schedule,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,20.64,102,,,fee schedule,Pays 102% Medicare OPPS,585,90,,,percent of total billed charges,90% of total billed charges,31.86,125.18,,,fee schedule,125.18% of custom fee schedule,446.55,68.7,,,percent of total billed charges,68.7% of total billed charges,520,80,,,percent of total billed charges,80 percent of total billed charges,20.23,100,,,fee schedule,Pays 100% Medicare OPPS,18.21,90,,,fee schedule,Pays 90% Medicare OPPS,377,58,,,percent of total billed charges,58% of total billed charges,30.63,120.37,,,fee schedule,120.37% of custom fee schedule,20.23,100,,,fee schedule,Pays 100% Medicare OPPS,26.31,130,APC,,fee schedule,Pays 130% Medicare OPPS,552.5,85,,,percent of total billed charges,85% of total billed charges,20.23,100,,,fee schedule,Pays 100% Medicare OPPS,18.21,585,
BREAST BIOPSY,4019102,CDM,320,RC,19081,HCPCS,Outpatient,,,650,520,,552.5,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,132.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,365.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1289.21,102,,,fee schedule,Pays 102% Medicare OPPS,585,90,,,percent of total billed charges,90% of total billed charges,227.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,446.55,68.7,,,percent of total billed charges,68.7% of total billed charges,520,80,,,percent of total billed charges,80 percent of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1137.55,90,,,fee schedule,Pays 90% Medicare OPPS,377,58,,,percent of total billed charges,58% of total billed charges,132.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1318.97,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,552.5,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,132.41,1714.66,
INCENTIVE SPIROMETER TX,5500002,CDM,410,RC,94640,HCPCS,Outpatient,,,650,520,,552.5,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,132.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,172.23,102,,,fee schedule,Pays 102% Medicare OPPS,585,90,,,percent of total billed charges,90% of total billed charges,227.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,446.55,68.7,,,percent of total billed charges,68.7% of total billed charges,520,80,,,percent of total billed charges,80 percent of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,151.96,90,,,fee schedule,Pays 90% Medicare OPPS,377,58,,,percent of total billed charges,58% of total billed charges,132.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,168.43,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,552.5,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,132.41,585,
INITIAL NEB TX,5500006,CDM,410,RC,94640,HCPCS,Outpatient,,,650,520,,552.5,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,132.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,172.23,102,,,fee schedule,Pays 102% Medicare OPPS,585,90,,,percent of total billed charges,90% of total billed charges,227.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,446.55,68.7,,,percent of total billed charges,68.7% of total billed charges,520,80,,,percent of total billed charges,80 percent of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,151.96,90,,,fee schedule,Pays 90% Medicare OPPS,377,58,,,percent of total billed charges,58% of total billed charges,132.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,168.43,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,552.5,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,132.41,585,
MYRINGOTOMY TRAY,7901541,CDM,270,RC,,,Outpatient,,,650,520,,552.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,132.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,585,90,,,percent of total billed charges,90% of total billed charges,227.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,446.55,68.7,,,percent of total billed charges,68.7% of total billed charges,520,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,377,58,,,percent of total billed charges,58% of total billed charges,132.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,552.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,132.41,585,
VITRECTOMY PAK,7950234,CDM,270,RC,,,Outpatient,,,650,520,,552.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,132.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,367.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,585,90,,,percent of total billed charges,90% of total billed charges,227.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,446.55,68.7,,,percent of total billed charges,68.7% of total billed charges,520,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,377,58,,,percent of total billed charges,58% of total billed charges,132.41,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,552.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,132.41,585,
LINEAR CUTTER RELOAD ECHELON BLUE GST60B,7950285,CDM,272,RC,,,Outpatient,,,655,524,,556.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,133.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,370.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,370.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,370.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,370.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,589.5,90,,,percent of total billed charges,90% of total billed charges,229.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,449.99,68.7,,,percent of total billed charges,68.7% of total billed charges,524,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,379.9,58,,,percent of total billed charges,58% of total billed charges,133.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,556.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,133.42,589.5,
LINEAR CUTTER RELOAD ECHELON GRN GST60G,7950286,CDM,272,RC,,,Outpatient,,,655,524,,556.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,133.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,370.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,370.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,370.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,370.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,589.5,90,,,percent of total billed charges,90% of total billed charges,229.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,449.99,68.7,,,percent of total billed charges,68.7% of total billed charges,524,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,379.9,58,,,percent of total billed charges,58% of total billed charges,133.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,556.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,133.42,589.5,
CIRCUMCISION SURG EXC NB,454150,CDM,723,RC,54150,HCPCS,Outpatient,,,660,528,,561,85,,,percent of total billed charges,85% of total billed charges,1608.44,100,,,fee schedule,Pays 100% Medicare OPPS,1608.44,100,,,fee schedule,Pays 100% Medicare OPPS,1608.44,100,,,fee schedule,Pays 100% Medicare OPPS,2120.96,130,,,fee schedule,Pays 130% Medicare OPPS,134.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1640.61,102,,,fee schedule,Pays 102% Medicare OPPS,594,90,,,percent of total billed charges,90% of total billed charges,231,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,453.42,68.7,,,percent of total billed charges,68.7% of total billed charges,528,80,,,percent of total billed charges,80 percent of total billed charges,1608.44,100,,,fee schedule,Pays 100% Medicare OPPS,1447.59,90,,,fee schedule,Pays 90% Medicare OPPS,382.8,58,,,percent of total billed charges,58% of total billed charges,134.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1631.51,100,,,fee schedule,Pays 100% Medicare OPPS,2120.96,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,1608.44,100,,,fee schedule,Pays 100% Medicare OPPS,134.44,2120.96,
PERITONOCENTESIS,1049080,CDM,761,RC,49083,HCPCS,Outpatient,,,660,528,,561,85,,,percent of total billed charges,85% of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,943.93,130,,,fee schedule,Pays 130% Medicare OPPS,134.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,741.4,102,,,fee schedule,Pays 102% Medicare OPPS,594,90,,,percent of total billed charges,90% of total billed charges,231,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,453.42,68.7,,,percent of total billed charges,68.7% of total billed charges,528,80,,,percent of total billed charges,80 percent of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,654.17,90,,,fee schedule,Pays 90% Medicare OPPS,382.8,58,,,percent of total billed charges,58% of total billed charges,134.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,726.1,100,,,fee schedule,Pays 100% Medicare OPPS,943.93,130,,,fee schedule,Pays 130% Medicare OPPS,561,85,,,percent of total billed charges,85% of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,134.44,943.93,
LAC INTRM 7.6-12.5CM,2012034,CDM,450,RC,,,Outpatient,,,660,528,,561,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,134.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,594,90,,,percent of total billed charges,90% of total billed charges,231,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,453.42,68.7,,,percent of total billed charges,68.7% of total billed charges,528,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,382.8,58,,,percent of total billed charges,58% of total billed charges,134.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,561,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,134.44,594,
FACIAL LAC INTRM <2.5CM,2012051,CDM,450,RC,12051,HCPCS,Outpatient,,,660,528,,561,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,134.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,316.7,102,,,fee schedule,Pays 102% Medicare OPPS,594,90,,,percent of total billed charges,90% of total billed charges,231,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,453.42,68.7,,,percent of total billed charges,68.7% of total billed charges,528,80,,,percent of total billed charges,80 percent of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,279.44,90,,,fee schedule,Pays 90% Medicare OPPS,382.8,58,,,percent of total billed charges,58% of total billed charges,134.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,328.14,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,561,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,134.44,594,
LAC INTRM 5.1 CM - 7.5 CM,2012053,CDM,450,RC,,,Outpatient,,,660,528,,561,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,134.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,594,90,,,percent of total billed charges,90% of total billed charges,231,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,453.42,68.7,,,percent of total billed charges,68.7% of total billed charges,528,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,382.8,58,,,percent of total billed charges,58% of total billed charges,134.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,561,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,134.44,594,
CREP H/A/5 CM OR LESS,2013133,CDM,450,RC,13133,HCPCS,Outpatient,,,660,528,,561,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,134.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,594,90,,,percent of total billed charges,90% of total billed charges,231,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,453.42,68.7,,,percent of total billed charges,68.7% of total billed charges,528,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,382.8,58,,,percent of total billed charges,58% of total billed charges,134.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,561,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,134.44,594,
Chemical test of the blood to measure presence or concentration of a substance in the blood,3000017,CDM,301,RC,83516,HCPCS,Outpatient,,,660,528,,561,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.76,102,,,fee schedule,Pays 102% Medicare OPPS,594,90,,,percent of total billed charges,90% of total billed charges,16.84,125.18,,,fee schedule,125.18% of custom fee schedule,453.42,68.7,,,percent of total billed charges,68.7% of total billed charges,528,80,,,percent of total billed charges,80 percent of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,90,,,fee schedule,Pays 90% Medicare OPPS,382.8,58,,,percent of total billed charges,58% of total billed charges,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,561,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,594,
Chemical test of the blood to measure presence or concentration of a substance in the blood,3000018,CDM,301,RC,83516,HCPCS,Outpatient,,,660,528,,561,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.76,102,,,fee schedule,Pays 102% Medicare OPPS,594,90,,,percent of total billed charges,90% of total billed charges,16.84,125.18,,,fee schedule,125.18% of custom fee schedule,453.42,68.7,,,percent of total billed charges,68.7% of total billed charges,528,80,,,percent of total billed charges,80 percent of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,90,,,fee schedule,Pays 90% Medicare OPPS,382.8,58,,,percent of total billed charges,58% of total billed charges,16.19,120.37,,,fee schedule,120.37% of custom fee schedule,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,561,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,594,
CHYLOMICRONS,3000578,CDM,301,RC,82664,HCPCS,Outpatient,,,660,528,,561,85,,,percent of total billed charges,85% of total billed charges,61.5,100,,,fee schedule,Pays 100% Medicare OPPS,61.5,100,,,fee schedule,Pays 100% Medicare OPPS,61.5,100,,,fee schedule,Pays 100% Medicare OPPS,79.95,130,,,fee schedule,Pays 130% Medicare OPPS,52,120.37,,,fee schedule,120.37% of custom fee schedule,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,62.73,102,,,fee schedule,Pays 102% Medicare OPPS,594,90,,,percent of total billed charges,90% of total billed charges,54.08,125.18,,,fee schedule,125.18% of custom fee schedule,453.42,68.7,,,percent of total billed charges,68.7% of total billed charges,528,80,,,percent of total billed charges,80 percent of total billed charges,61.5,100,,,fee schedule,Pays 100% Medicare OPPS,55.35,90,,,fee schedule,Pays 90% Medicare OPPS,382.8,58,,,percent of total billed charges,58% of total billed charges,52,120.37,,,fee schedule,120.37% of custom fee schedule,61.5,100,,,fee schedule,Pays 100% Medicare OPPS,79.95,130,,,fee schedule,Pays 130% Medicare OPPS,561,85,,,percent of total billed charges,85% of total billed charges,61.5,100,,,fee schedule,Pays 100% Medicare OPPS,52,594,
3RD ADALIMUMAB AND ANTI ADALIMUMAB AB,3000741,CDM,301,RC,83520,HCPCS,Outpatient,,,660,528,,561,85,,,percent of total billed charges,85% of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,130,,,fee schedule,Pays 130% Medicare OPPS,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.61,102,,,fee schedule,Pays 102% Medicare OPPS,594,90,,,percent of total billed charges,90% of total billed charges,20.38,125.18,,,fee schedule,125.18% of custom fee schedule,453.42,68.7,,,percent of total billed charges,68.7% of total billed charges,528,80,,,percent of total billed charges,80 percent of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,15.54,90,,,fee schedule,Pays 90% Medicare OPPS,382.8,58,,,percent of total billed charges,58% of total billed charges,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,130,,,fee schedule,Pays 130% Medicare OPPS,561,85,,,percent of total billed charges,85% of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,15.54,594,
3RD EBV DNA QUANTITATIVE,3000899,CDM,301,RC,87798,HCPCS,Outpatient,,,660,528,,561,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,,,fee schedule,Pays 130% Medicare OPPS,29.7,120.37,,,fee schedule,120.37% of custom fee schedule,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,35.79,102,,,fee schedule,Pays 102% Medicare OPPS,594,90,,,percent of total billed charges,90% of total billed charges,30.88,125.18,,,fee schedule,125.18% of custom fee schedule,453.42,68.7,,,percent of total billed charges,68.7% of total billed charges,528,80,,,percent of total billed charges,80 percent of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,31.58,90,,,fee schedule,Pays 90% Medicare OPPS,382.8,58,,,percent of total billed charges,58% of total billed charges,29.7,120.37,,,fee schedule,120.37% of custom fee schedule,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,,,fee schedule,Pays 130% Medicare OPPS,561,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,29.7,594,
3RD 6-MERCAPTOPURINE,3084291,CDM,301,RC,,,Outpatient,,,660,528,,561,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,134.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,594,90,,,percent of total billed charges,90% of total billed charges,231,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,453.42,68.7,,,percent of total billed charges,68.7% of total billed charges,528,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,382.8,58,,,percent of total billed charges,58% of total billed charges,134.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,561,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,134.44,594,
MYELOGRAM TRAY,4000805,CDM,270,RC,,,Outpatient,,,660,528,,561,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,134.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,594,90,,,percent of total billed charges,90% of total billed charges,231,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,453.42,68.7,,,percent of total billed charges,68.7% of total billed charges,528,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,382.8,58,,,percent of total billed charges,58% of total billed charges,134.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,561,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,134.44,594,
XR CHEST FLUOROSCOPY,4071023,CDM,324,RC,71023,HCPCS,Outpatient,,,660,528,,561,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,134.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,370.92,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,594,90,,,percent of total billed charges,90% of total billed charges,231,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,453.42,68.7,,,percent of total billed charges,68.7% of total billed charges,528,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,382.8,58,,,percent of total billed charges,58% of total billed charges,134.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,561,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,134.44,594,
PERITONOCENTESIS,4649080,CDM,402,RC,49083,HCPCS,Outpatient,,,660,528,,561,85,,,percent of total billed charges,85% of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,943.93,130,,,fee schedule,Pays 130% Medicare OPPS,134.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,370.92,56.5,,,percent of total billed charges,56.5 percent of total billed charges,741.4,102,,,fee schedule,Pays 102% Medicare OPPS,594,90,,,percent of total billed charges,90% of total billed charges,231,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,453.42,68.7,,,percent of total billed charges,68.7% of total billed charges,528,80,,,percent of total billed charges,80 percent of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,654.17,90,,,fee schedule,Pays 90% Medicare OPPS,382.8,58,,,percent of total billed charges,58% of total billed charges,134.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,726.1,100,,,fee schedule,Pays 100% Medicare OPPS,943.93,130,,,fee schedule,Pays 130% Medicare OPPS,561,85,,,percent of total billed charges,85% of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,134.44,943.93,
US 1ST TRIM FETAL NUC MEA EACH ADDITION,4676814,CDM,402,RC,76814,HCPCS,Outpatient,,,660,528,,561,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,134.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,370.92,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,594,90,,,percent of total billed charges,90% of total billed charges,231,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,453.42,68.7,,,percent of total billed charges,68.7% of total billed charges,528,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,382.8,58,,,percent of total billed charges,58% of total billed charges,134.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,561,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,134.44,594,
CARDIOPULMONARY RESUSCITA,5592950,CDM,480,RC,92950,HCPCS,Outpatient,,,660,528,,561,85,,,percent of total billed charges,85% of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,320.22,130,,,fee schedule,Pays 130% Medicare OPPS,134.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,242.49,102,,,fee schedule,Pays 102% Medicare OPPS,594,90,,,percent of total billed charges,90% of total billed charges,231,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,453.42,68.7,,,percent of total billed charges,68.7% of total billed charges,528,80,,,percent of total billed charges,80 percent of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,213.96,90,,,fee schedule,Pays 90% Medicare OPPS,382.8,58,,,percent of total billed charges,58% of total billed charges,134.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,246.33,100,,,fee schedule,Pays 100% Medicare OPPS,320.22,130,,,fee schedule,Pays 130% Medicare OPPS,561,85,,,percent of total billed charges,85% of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,134.44,986.63,
Test to determine if wheezing is present,5594060,CDM,460,RC,94060,HCPCS,Outpatient,,,660,528,,561,85,,,percent of total billed charges,85% of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,320.22,130,,,fee schedule,Pays 130% Medicare OPPS,134.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,372.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,242.49,102,,,fee schedule,Pays 102% Medicare OPPS,594,90,,,percent of total billed charges,90% of total billed charges,231,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,453.42,68.7,,,percent of total billed charges,68.7% of total billed charges,528,80,,,percent of total billed charges,80 percent of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,213.96,90,,,fee schedule,Pays 90% Medicare OPPS,382.8,58,,,percent of total billed charges,58% of total billed charges,134.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,246.33,100,,,fee schedule,Pays 100% Medicare OPPS,320.22,130,,,fee schedule,Pays 130% Medicare OPPS,561,85,,,percent of total billed charges,85% of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,134.44,594,
LAC SIMPLE 2.6-7.5CM,2012002,CDM,450,RC,,,Outpatient,,,665,532,,565.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,135.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,598.5,90,,,percent of total billed charges,90% of total billed charges,232.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,456.86,68.7,,,percent of total billed charges,68.7% of total billed charges,532,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,385.7,58,,,percent of total billed charges,58% of total billed charges,135.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,565.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,135.46,598.5,
FACIAL LAC SIMPLE 2.6-5.0CM,2012013,CDM,450,RC,,,Outpatient,,,665,532,,565.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,135.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,598.5,90,,,percent of total billed charges,90% of total billed charges,232.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,456.86,68.7,,,percent of total billed charges,68.7% of total billed charges,532,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,385.7,58,,,percent of total billed charges,58% of total billed charges,135.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,565.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,135.46,598.5,
LEVEL II EMERGENCY ROOM,2099282,CDM,450,RC,99282,HCPCS,Outpatient,,,665,532,,565.25,85,,,percent of total billed charges,85% of total billed charges,117.99,100,,,fee schedule,Pays 100% Medicare OPPS,117.99,100,,,fee schedule,Pays 100% Medicare OPPS,117.99,100,,,fee schedule,Pays 100% Medicare OPPS,159.72,130,,,fee schedule,Pays 130% Medicare OPPS,135.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,665,100,,,percent of total billed charges,671 dollar flat fee for ER,665,100,,,percent of total billed charges,671 dollar flat fee for ER,665,100,,,percent of total billed charges,671 dollar flat fee for ER,665,100,,,percent of total billed charges,671 dollar flat fee for ER,120.35,102,,,fee schedule,Pays 102% Medicare OPPS,598.5,90,,,percent of total billed charges,90% of total billed charges,232.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,456.86,68.7,,,percent of total billed charges,68.7% of total billed charges,532,80,,,percent of total billed charges,80 percent of total billed charges,117.99,100,,,fee schedule,Pays 100% Medicare OPPS,106.19,90,,,fee schedule,Pays 90% Medicare OPPS,385.7,58,,,percent of total billed charges,58% of total billed charges,135.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,122.86,100,,,fee schedule,Pays 100% Medicare OPPS,159.72,130,,,fee schedule,Pays 130% Medicare OPPS,565.25,85,,,percent of total billed charges,85% of total billed charges,117.99,100,,,fee schedule,Pays 100% Medicare OPPS,106.19,665,
"Radiologic examination of the neck/spine, 4-5 views",4072050,CDM,320,RC,72050,HCPCS,Outpatient,,,665,532,,565.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,135.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,373.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,598.5,90,,,percent of total billed charges,90% of total billed charges,232.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,456.86,68.7,,,percent of total billed charges,68.7% of total billed charges,532,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,385.7,58,,,percent of total billed charges,58% of total billed charges,135.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,565.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,598.5,
XR SPINE THORACIC 4 VIEWS,4072074,CDM,320,RC,72074,HCPCS,Outpatient,,,665,532,,565.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,135.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,373.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,598.5,90,,,percent of total billed charges,90% of total billed charges,232.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,456.86,68.7,,,percent of total billed charges,68.7% of total billed charges,532,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,385.7,58,,,percent of total billed charges,58% of total billed charges,135.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,565.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,598.5,
"X-ray of lower and sacral spine, minimum of 4 views",4072110,CDM,320,RC,72110,HCPCS,Outpatient,,,665,532,,565.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,135.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,373.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,598.5,90,,,percent of total billed charges,90% of total billed charges,232.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,456.86,68.7,,,percent of total billed charges,68.7% of total billed charges,532,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,385.7,58,,,percent of total billed charges,58% of total billed charges,135.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,565.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,598.5,
XR SPINE/LUMBAR W/FLEX EXT,4072114,CDM,320,RC,72114,HCPCS,Outpatient,,,665,532,,565.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,135.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,373.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,598.5,90,,,percent of total billed charges,90% of total billed charges,232.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,456.86,68.7,,,percent of total billed charges,68.7% of total billed charges,532,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,385.7,58,,,percent of total billed charges,58% of total billed charges,135.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,565.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,598.5,
MM MAMMOGRAM/BIOPSY,4376096,CDM,409,RC,77032,HCPCS,Outpatient,,,665,532,,565.25,85,,,percent of total billed charges,85% of total billed charges,166.25,100,,,fee schedule,Pays 100% Medicare OPPS,166.25,100,,,fee schedule,Pays 100% Medicare OPPS,166.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,135.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,373.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,598.5,90,,,percent of total billed charges,90% of total billed charges,232.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,456.86,68.7,,,percent of total billed charges,68.7% of total billed charges,532,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,598.5,90,,,fee schedule,Pays 90% Medicare OPPS,385.7,58,,,percent of total billed charges,58% of total billed charges,135.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,135.46,598.5,
SPLINT SAMMONS PRESTON HUMERUS,7900501,CDM,270,RC,,,Outpatient,,,665,532,,565.25,85,,,percent of total billed charges,85% of total billed charges,166.25,100,,,fee schedule,Pays 100% Medicare OPPS,166.25,100,,,fee schedule,Pays 100% Medicare OPPS,166.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,135.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,598.5,90,,,percent of total billed charges,90% of total billed charges,232.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,456.86,68.7,,,percent of total billed charges,68.7% of total billed charges,532,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,598.5,90,,,fee schedule,Pays 90% Medicare OPPS,385.7,58,,,percent of total billed charges,58% of total billed charges,135.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,565.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,135.46,598.5,
CATH NASAL 1527031,7950101,CDM,270,RC,,,Outpatient,,,665,532,,565.25,85,,,percent of total billed charges,85% of total billed charges,166.25,100,,,fee schedule,Pays 100% Medicare OPPS,166.25,100,,,fee schedule,Pays 100% Medicare OPPS,166.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,135.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,375.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,598.5,90,,,percent of total billed charges,90% of total billed charges,232.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,456.86,68.7,,,percent of total billed charges,68.7% of total billed charges,532,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,598.5,90,,,fee schedule,Pays 90% Medicare OPPS,385.7,58,,,percent of total billed charges,58% of total billed charges,135.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,565.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,135.46,598.5,
G TUBE REPLACEMENT,1743760,CDM,361,RC,,,Outpatient,,,675,540,,573.75,85,,,percent of total billed charges,85% of total billed charges,168.75,100,,,fee schedule,Pays 100% Medicare OPPS,168.75,100,,,fee schedule,Pays 100% Medicare OPPS,168.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,137.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,607.5,90,,,percent of total billed charges,90% of total billed charges,236.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,463.73,68.7,,,percent of total billed charges,68.7% of total billed charges,540,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,607.5,90,,,fee schedule,Pays 90% Medicare OPPS,391.5,58,,,percent of total billed charges,58% of total billed charges,137.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,573.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,137.5,607.5,
Destruction of pre-cancerous lesion,2017000,CDM,490,RC,17000,HCPCS,Outpatient,,,675,540,,573.75,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,137.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,164.54,102,,,fee schedule,Pays 102% Medicare OPPS,607.5,90,,,percent of total billed charges,90% of total billed charges,236.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,463.73,68.7,,,percent of total billed charges,68.7% of total billed charges,540,80,,,percent of total billed charges,80 percent of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,145.18,90,,,fee schedule,Pays 90% Medicare OPPS,391.5,58,,,percent of total billed charges,58% of total billed charges,137.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.83,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,573.75,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,137.5,986.63,
PYRUVATE,3084210,CDM,301,RC,84210,HCPCS,Outpatient,,,675,540,,573.75,85,,,percent of total billed charges,85% of total billed charges,14.48,100,,,fee schedule,Pays 100% Medicare OPPS,14.48,100,,,fee schedule,Pays 100% Medicare OPPS,14.48,100,,,fee schedule,Pays 100% Medicare OPPS,18.82,130,,,fee schedule,Pays 130% Medicare OPPS,16.43,120.37,,,fee schedule,120.37% of custom fee schedule,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.76,102,,,fee schedule,Pays 102% Medicare OPPS,607.5,90,,,percent of total billed charges,90% of total billed charges,17.09,125.18,,,fee schedule,125.18% of custom fee schedule,463.73,68.7,,,percent of total billed charges,68.7% of total billed charges,540,80,,,percent of total billed charges,80 percent of total billed charges,14.48,100,,,fee schedule,Pays 100% Medicare OPPS,13.03,90,,,fee schedule,Pays 90% Medicare OPPS,391.5,58,,,percent of total billed charges,58% of total billed charges,16.43,120.37,,,fee schedule,120.37% of custom fee schedule,14.48,100,,,fee schedule,Pays 100% Medicare OPPS,18.82,130,,,fee schedule,Pays 130% Medicare OPPS,573.75,85,,,percent of total billed charges,85% of total billed charges,14.48,100,,,fee schedule,Pays 100% Medicare OPPS,13.03,607.5,
.30 CELL COUNT(CHROMOSOME,3088262,CDM,311,RC,88262,HCPCS,Outpatient,,,675,540,,573.75,85,,,percent of total billed charges,85% of total billed charges,125.49,100,,,fee schedule,Pays 100% Medicare OPPS,125.49,100,,,fee schedule,Pays 100% Medicare OPPS,125.49,100,,,fee schedule,Pays 100% Medicare OPPS,163.13,130,,,fee schedule,Pays 130% Medicare OPPS,188.66,120.37,,,fee schedule,120.37% of custom fee schedule,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,127.99,102,,,fee schedule,Pays 102% Medicare OPPS,607.5,90,,,percent of total billed charges,90% of total billed charges,196.19,125.18,,,fee schedule,125.18% of custom fee schedule,463.73,68.7,,,percent of total billed charges,68.7% of total billed charges,540,80,,,percent of total billed charges,80 percent of total billed charges,125.49,100,,,fee schedule,Pays 100% Medicare OPPS,112.94,90,,,fee schedule,Pays 90% Medicare OPPS,391.5,58,,,percent of total billed charges,58% of total billed charges,188.66,120.37,,,fee schedule,120.37% of custom fee schedule,125.49,100,,,fee schedule,Pays 100% Medicare OPPS,163.13,130,,,fee schedule,Pays 130% Medicare OPPS,573.75,85,,,percent of total billed charges,85% of total billed charges,125.49,100,,,fee schedule,Pays 100% Medicare OPPS,112.94,607.5,
.3 KARYOTYPES & BANDING,3088280,CDM,311,RC,88280,HCPCS,Outpatient,,,675,540,,573.75,85,,,percent of total billed charges,85% of total billed charges,33.47,100,,,fee schedule,Pays 100% Medicare OPPS,33.47,100,,,fee schedule,Pays 100% Medicare OPPS,33.47,100,,,fee schedule,Pays 100% Medicare OPPS,43.51,130,,,fee schedule,Pays 130% Medicare OPPS,37.99,120.37,,,fee schedule,120.37% of custom fee schedule,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,34.13,102,,,fee schedule,Pays 102% Medicare OPPS,607.5,90,,,percent of total billed charges,90% of total billed charges,39.51,125.18,,,fee schedule,125.18% of custom fee schedule,463.73,68.7,,,percent of total billed charges,68.7% of total billed charges,540,80,,,percent of total billed charges,80 percent of total billed charges,33.47,100,,,fee schedule,Pays 100% Medicare OPPS,30.12,90,,,fee schedule,Pays 90% Medicare OPPS,391.5,58,,,percent of total billed charges,58% of total billed charges,37.99,120.37,,,fee schedule,120.37% of custom fee schedule,33.47,100,,,fee schedule,Pays 100% Medicare OPPS,43.51,130,,,fee schedule,Pays 130% Medicare OPPS,573.75,85,,,percent of total billed charges,85% of total billed charges,33.47,100,,,fee schedule,Pays 100% Medicare OPPS,30.12,607.5,
G TUBE REPLACEMENT,4043760,CDM,361,RC,,,Outpatient,,,675,540,,573.75,85,,,percent of total billed charges,85% of total billed charges,168.75,100,,,fee schedule,Pays 100% Medicare OPPS,168.75,100,,,fee schedule,Pays 100% Medicare OPPS,168.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,137.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,607.5,90,,,percent of total billed charges,90% of total billed charges,236.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,463.73,68.7,,,percent of total billed charges,68.7% of total billed charges,540,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,607.5,90,,,fee schedule,Pays 90% Medicare OPPS,391.5,58,,,percent of total billed charges,58% of total billed charges,137.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,573.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,137.5,607.5,
Transvaginal ultrasound of uterus,4676817,CDM,402,RC,76817,HCPCS,Outpatient,,,675,540,,573.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,137.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,379.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,607.5,90,,,percent of total billed charges,90% of total billed charges,236.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,463.73,68.7,,,percent of total billed charges,68.7% of total billed charges,540,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,391.5,58,,,percent of total billed charges,58% of total billed charges,137.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,573.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,607.5,
Ultrasound of the pelvis through vagina,4676830,CDM,402,RC,76830,HCPCS,Outpatient,,,675,540,,573.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,137.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,379.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,607.5,90,,,percent of total billed charges,90% of total billed charges,236.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,463.73,68.7,,,percent of total billed charges,68.7% of total billed charges,540,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,391.5,58,,,percent of total billed charges,58% of total billed charges,137.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,573.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,607.5,
EVENT MONITOR,5693270,CDM,731,RC,93270,HCPCS,Outpatient,,,675,540,,573.75,85,,,percent of total billed charges,85% of total billed charges,33.45,100,,,fee schedule,Pays 100% Medicare OPPS,33.45,100,,,fee schedule,Pays 100% Medicare OPPS,33.45,100,,,fee schedule,Pays 100% Medicare OPPS,40.02,130,,,fee schedule,Pays 130% Medicare OPPS,137.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,34.11,102,,,fee schedule,Pays 102% Medicare OPPS,607.5,90,,,percent of total billed charges,90% of total billed charges,236.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,463.73,68.7,,,percent of total billed charges,68.7% of total billed charges,540,80,,,percent of total billed charges,80 percent of total billed charges,33.45,100,,,fee schedule,Pays 100% Medicare OPPS,30.1,90,,,fee schedule,Pays 90% Medicare OPPS,391.5,58,,,percent of total billed charges,58% of total billed charges,137.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,30.78,100,,,fee schedule,Pays 100% Medicare OPPS,40.02,130,,,fee schedule,Pays 130% Medicare OPPS,573.75,85,,,percent of total billed charges,85% of total billed charges,33.45,100,,,fee schedule,Pays 100% Medicare OPPS,30.1,607.5,
CATH KIT CENTRAL VENOUS CDC-45703-P1A,7905496,CDM,270,RC,,,Outpatient,,,675,540,,573.75,85,,,percent of total billed charges,85% of total billed charges,168.75,100,,,fee schedule,Pays 100% Medicare OPPS,168.75,100,,,fee schedule,Pays 100% Medicare OPPS,168.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,137.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,381.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,607.5,90,,,percent of total billed charges,90% of total billed charges,236.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,463.73,68.7,,,percent of total billed charges,68.7% of total billed charges,540,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,607.5,90,,,fee schedule,Pays 90% Medicare OPPS,391.5,58,,,percent of total billed charges,58% of total billed charges,137.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,573.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,137.5,607.5,
CLOSE TREATMENT SHOULDER DISL W MANIPULA,2023545,CDM,450,RC,23545,HCPCS,Outpatient,,,685,548,,582.25,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,188.85,102,,,fee schedule,Pays 102% Medicare OPPS,616.5,90,,,percent of total billed charges,90% of total billed charges,239.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,470.6,68.7,,,percent of total billed charges,68.7% of total billed charges,548,80,,,percent of total billed charges,80 percent of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,166.63,90,,,fee schedule,Pays 90% Medicare OPPS,397.3,58,,,percent of total billed charges,58% of total billed charges,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,182.08,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,582.25,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,139.53,616.5,
FX HUMERUS TX ELBOW,2023605,CDM,450,RC,,,Outpatient,,,685,548,,582.25,85,,,percent of total billed charges,85% of total billed charges,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,percent of total billed charges,90% of total billed charges,239.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,470.6,68.7,,,percent of total billed charges,68.7% of total billed charges,548,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,fee schedule,Pays 90% Medicare OPPS,397.3,58,,,percent of total billed charges,58% of total billed charges,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,582.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,139.53,616.5,
DISLOC SHOULDER WO ANESTH,2023650,CDM,450,RC,23650,HCPCS,Outpatient,,,685,548,,582.25,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,188.85,102,,,fee schedule,Pays 102% Medicare OPPS,616.5,90,,,percent of total billed charges,90% of total billed charges,239.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,470.6,68.7,,,percent of total billed charges,68.7% of total billed charges,548,80,,,percent of total billed charges,80 percent of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,166.63,90,,,fee schedule,Pays 90% Medicare OPPS,397.3,58,,,percent of total billed charges,58% of total billed charges,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,182.08,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,582.25,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,139.53,616.5,
FX HUMERUS CLOSED,2024500,CDM,450,RC,,,Outpatient,,,685,548,,582.25,85,,,percent of total billed charges,85% of total billed charges,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,percent of total billed charges,90% of total billed charges,239.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,470.6,68.7,,,percent of total billed charges,68.7% of total billed charges,548,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,fee schedule,Pays 90% Medicare OPPS,397.3,58,,,percent of total billed charges,58% of total billed charges,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,582.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,139.53,616.5,
DISLOC ELBOW TX,2024600,CDM,450,RC,24600,HCPCS,Outpatient,,,685,548,,582.25,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,188.85,102,,,fee schedule,Pays 102% Medicare OPPS,616.5,90,,,percent of total billed charges,90% of total billed charges,239.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,470.6,68.7,,,percent of total billed charges,68.7% of total billed charges,548,80,,,percent of total billed charges,80 percent of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,166.63,90,,,fee schedule,Pays 90% Medicare OPPS,397.3,58,,,percent of total billed charges,58% of total billed charges,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,182.08,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,582.25,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,139.53,616.5,
DISLOC ELBOW CHILD(NURSEMAIDS),2024640,CDM,450,RC,24640,HCPCS,Outpatient,,,685,548,,582.25,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,188.85,102,,,fee schedule,Pays 102% Medicare OPPS,616.5,90,,,percent of total billed charges,90% of total billed charges,239.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,470.6,68.7,,,percent of total billed charges,68.7% of total billed charges,548,80,,,percent of total billed charges,80 percent of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,166.63,90,,,fee schedule,Pays 90% Medicare OPPS,397.3,58,,,percent of total billed charges,58% of total billed charges,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,182.08,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,582.25,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,139.53,616.5,
FX ELBOW CLOSED,2024655,CDM,450,RC,,,Outpatient,,,685,548,,582.25,85,,,percent of total billed charges,85% of total billed charges,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,percent of total billed charges,90% of total billed charges,239.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,470.6,68.7,,,percent of total billed charges,68.7% of total billed charges,548,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,fee schedule,Pays 90% Medicare OPPS,397.3,58,,,percent of total billed charges,58% of total billed charges,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,582.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,139.53,616.5,
FX RADIUS CLOSED,2025500,CDM,450,RC,,,Outpatient,,,685,548,,582.25,85,,,percent of total billed charges,85% of total billed charges,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,percent of total billed charges,90% of total billed charges,239.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,470.6,68.7,,,percent of total billed charges,68.7% of total billed charges,548,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,fee schedule,Pays 90% Medicare OPPS,397.3,58,,,percent of total billed charges,58% of total billed charges,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,582.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,139.53,616.5,
FX ULNAR CLOSED,2025530,CDM,450,RC,25530,HCPCS,Outpatient,,,685,548,,582.25,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,188.85,102,,,fee schedule,Pays 102% Medicare OPPS,616.5,90,,,percent of total billed charges,90% of total billed charges,239.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,470.6,68.7,,,percent of total billed charges,68.7% of total billed charges,548,80,,,percent of total billed charges,80 percent of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,166.63,90,,,fee schedule,Pays 90% Medicare OPPS,397.3,58,,,percent of total billed charges,58% of total billed charges,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,182.08,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,582.25,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,139.53,616.5,
FX RAD OR ULNAR CLOSED,2025560,CDM,450,RC,,,Outpatient,,,685,548,,582.25,85,,,percent of total billed charges,85% of total billed charges,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,percent of total billed charges,90% of total billed charges,239.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,470.6,68.7,,,percent of total billed charges,68.7% of total billed charges,548,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,fee schedule,Pays 90% Medicare OPPS,397.3,58,,,percent of total billed charges,58% of total billed charges,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,582.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,139.53,616.5,
FX RAD & ULNAR CLOSED W/MANIPULATION,2025565,CDM,450,RC,,,Outpatient,,,685,548,,582.25,85,,,percent of total billed charges,85% of total billed charges,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,percent of total billed charges,90% of total billed charges,239.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,470.6,68.7,,,percent of total billed charges,68.7% of total billed charges,548,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,fee schedule,Pays 90% Medicare OPPS,397.3,58,,,percent of total billed charges,58% of total billed charges,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,582.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,139.53,616.5,
FX METACARPAL CLOSED,2026605,CDM,450,RC,,,Outpatient,,,685,548,,582.25,85,,,percent of total billed charges,85% of total billed charges,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,percent of total billed charges,90% of total billed charges,239.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,470.6,68.7,,,percent of total billed charges,68.7% of total billed charges,548,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,fee schedule,Pays 90% Medicare OPPS,397.3,58,,,percent of total billed charges,58% of total billed charges,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,582.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,139.53,616.5,
DISLOC THUMB TX,2026641,CDM,450,RC,26641,HCPCS,Outpatient,,,685,548,,582.25,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,188.85,102,,,fee schedule,Pays 102% Medicare OPPS,616.5,90,,,percent of total billed charges,90% of total billed charges,239.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,470.6,68.7,,,percent of total billed charges,68.7% of total billed charges,548,80,,,percent of total billed charges,80 percent of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,166.63,90,,,fee schedule,Pays 90% Medicare OPPS,397.3,58,,,percent of total billed charges,58% of total billed charges,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,182.08,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,582.25,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,139.53,616.5,
DISLOC FINGER TX,2026770,CDM,450,RC,,,Outpatient,,,685,548,,582.25,85,,,percent of total billed charges,85% of total billed charges,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,percent of total billed charges,90% of total billed charges,239.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,470.6,68.7,,,percent of total billed charges,68.7% of total billed charges,548,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,fee schedule,Pays 90% Medicare OPPS,397.3,58,,,percent of total billed charges,58% of total billed charges,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,582.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,139.53,616.5,
DISLOCATED HIP CLOSED,2027252,CDM,450,RC,27252,HCPCS,Outpatient,,,685,548,,582.25,85,,,percent of total billed charges,85% of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1640.3,130,,,fee schedule,Pays 130% Medicare OPPS,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1276.23,102,,,fee schedule,Pays 102% Medicare OPPS,616.5,90,,,percent of total billed charges,90% of total billed charges,239.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,470.6,68.7,,,percent of total billed charges,68.7% of total billed charges,548,80,,,percent of total billed charges,80 percent of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1126.08,90,,,fee schedule,Pays 90% Medicare OPPS,397.3,58,,,percent of total billed charges,58% of total billed charges,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1261.77,100,,,fee schedule,Pays 100% Medicare OPPS,1640.3,130,,,fee schedule,Pays 130% Medicare OPPS,582.25,85,,,percent of total billed charges,85% of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,139.53,1640.3,
DISLOC KNEE TX,2027550,CDM,450,RC,27550,HCPCS,Outpatient,,,685,548,,582.25,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,188.85,102,,,fee schedule,Pays 102% Medicare OPPS,616.5,90,,,percent of total billed charges,90% of total billed charges,239.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,470.6,68.7,,,percent of total billed charges,68.7% of total billed charges,548,80,,,percent of total billed charges,80 percent of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,166.63,90,,,fee schedule,Pays 90% Medicare OPPS,397.3,58,,,percent of total billed charges,58% of total billed charges,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,182.08,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,582.25,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,139.53,616.5,
FX PATELLA CLOSED,2027560,CDM,450,RC,,,Outpatient,,,685,548,,582.25,85,,,percent of total billed charges,85% of total billed charges,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,percent of total billed charges,90% of total billed charges,239.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,470.6,68.7,,,percent of total billed charges,68.7% of total billed charges,548,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,fee schedule,Pays 90% Medicare OPPS,397.3,58,,,percent of total billed charges,58% of total billed charges,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,582.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,139.53,616.5,
FX TIBIA CLOSED,2027752,CDM,450,RC,,,Outpatient,,,685,548,,582.25,85,,,percent of total billed charges,85% of total billed charges,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,percent of total billed charges,90% of total billed charges,239.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,470.6,68.7,,,percent of total billed charges,68.7% of total billed charges,548,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,fee schedule,Pays 90% Medicare OPPS,397.3,58,,,percent of total billed charges,58% of total billed charges,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,582.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,139.53,616.5,
FX ANKLE CLOSED REDUCTION W/MANIPULATION,2027810,CDM,450,RC,,,Outpatient,,,685,548,,582.25,85,,,percent of total billed charges,85% of total billed charges,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,percent of total billed charges,90% of total billed charges,239.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,470.6,68.7,,,percent of total billed charges,68.7% of total billed charges,548,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,fee schedule,Pays 90% Medicare OPPS,397.3,58,,,percent of total billed charges,58% of total billed charges,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,582.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,139.53,616.5,
I&D PERIRECTAL OR ISCHIAL ABSCESS,2046040,CDM,450,RC,46040,HCPCS,Outpatient,,,685,548,,582.25,85,,,percent of total billed charges,85% of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,1238.25,130,,,fee schedule,Pays 130% Medicare OPPS,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,950.15,102,,,fee schedule,Pays 102% Medicare OPPS,616.5,90,,,percent of total billed charges,90% of total billed charges,239.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,470.6,68.7,,,percent of total billed charges,68.7% of total billed charges,548,80,,,percent of total billed charges,80 percent of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,838.37,90,,,fee schedule,Pays 90% Medicare OPPS,397.3,58,,,percent of total billed charges,58% of total billed charges,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,952.5,100,,,fee schedule,Pays 100% Medicare OPPS,1238.25,130,,,fee schedule,Pays 130% Medicare OPPS,582.25,85,,,percent of total billed charges,85% of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,139.53,1238.25,
NON-FORM IVPB/IVF IV : 1ML,2600089,CDM,250,RC,,,Outpatient,,,685,548,,582.25,85,,,percent of total billed charges,85% of total billed charges,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,percent of total billed charges,90% of total billed charges,239.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,470.6,68.7,,,percent of total billed charges,68.7% of total billed charges,548,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,fee schedule,Pays 90% Medicare OPPS,397.3,58,,,percent of total billed charges,58% of total billed charges,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,582.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,139.53,616.5,
NON-FORMULARY ABX LIQ : 1ML,2609505,CDM,637,RC,,,Outpatient,,,685,548,,582.25,85,,,percent of total billed charges,85% of total billed charges,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,percent of total billed charges,90% of total billed charges,239.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,470.6,68.7,,,percent of total billed charges,68.7% of total billed charges,548,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,fee schedule,Pays 90% Medicare OPPS,397.3,58,,,percent of total billed charges,58% of total billed charges,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,582.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,139.53,616.5,
LABOR CHECK,4000010,CDM,729,RC,,,Outpatient,,,685,548,,582.25,85,,,percent of total billed charges,85% of total billed charges,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,percent of total billed charges,90% of total billed charges,239.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,470.6,68.7,,,percent of total billed charges,68.7% of total billed charges,548,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,fee schedule,Pays 90% Medicare OPPS,397.3,58,,,percent of total billed charges,58% of total billed charges,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,139.53,616.5,
PEG KIT ENDOVIVE SAFETY 20FR,7905847,CDM,270,RC,,,Outpatient,,,685,548,,582.25,85,,,percent of total billed charges,85% of total billed charges,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,percent of total billed charges,90% of total billed charges,239.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,470.6,68.7,,,percent of total billed charges,68.7% of total billed charges,548,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,fee schedule,Pays 90% Medicare OPPS,397.3,58,,,percent of total billed charges,58% of total billed charges,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,582.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,139.53,616.5,
ENDO CLIP APPLIER EL5ML,7950146,CDM,270,RC,,,Outpatient,,,685,548,,582.25,85,,,percent of total billed charges,85% of total billed charges,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,171.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,387.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,percent of total billed charges,90% of total billed charges,239.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,470.6,68.7,,,percent of total billed charges,68.7% of total billed charges,548,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,616.5,90,,,fee schedule,Pays 90% Medicare OPPS,397.3,58,,,percent of total billed charges,58% of total billed charges,139.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,582.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,139.53,616.5,
COMBIVENT (IPRATROPIUM/ALBUT) INH,2603051,CDM,250,RC,,,Outpatient,,,690,552,,586.5,85,,,percent of total billed charges,85% of total billed charges,172.5,100,,,fee schedule,Pays 100% Medicare OPPS,172.5,100,,,fee schedule,Pays 100% Medicare OPPS,172.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,140.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,389.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,389.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,389.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,389.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,621,90,,,percent of total billed charges,90% of total billed charges,241.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,474.03,68.7,,,percent of total billed charges,68.7% of total billed charges,552,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,621,90,,,fee schedule,Pays 90% Medicare OPPS,400.2,58,,,percent of total billed charges,58% of total billed charges,140.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,586.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,140.55,621,
.HEPATITIS AMP OF PNA,3000145,CDM,301,RC,81223,HCPCS,Outpatient,,,690,552,,586.5,85,,,percent of total billed charges,85% of total billed charges,499,100,,,fee schedule,Pays 100% Medicare OPPS,499,100,,,fee schedule,Pays 100% Medicare OPPS,499,100,,,fee schedule,Pays 100% Medicare OPPS,648.7,130,,,fee schedule,Pays 130% Medicare OPPS,1155.55,120.37,,,fee schedule,120.37% of custom fee schedule,389.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,389.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,389.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,389.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,508.98,102,,,fee schedule,Pays 102% Medicare OPPS,621,90,,,percent of total billed charges,90% of total billed charges,1201.73,125.18,,,fee schedule,125.18% of custom fee schedule,474.03,68.7,,,percent of total billed charges,68.7% of total billed charges,552,80,,,percent of total billed charges,80 percent of total billed charges,499,100,,,fee schedule,Pays 100% Medicare OPPS,449.1,90,,,fee schedule,Pays 90% Medicare OPPS,400.2,58,,,percent of total billed charges,58% of total billed charges,1155.55,120.37,,,fee schedule,120.37% of custom fee schedule,499,100,,,fee schedule,Pays 100% Medicare OPPS,648.7,130,,,fee schedule,Pays 130% Medicare OPPS,586.5,85,,,percent of total billed charges,85% of total billed charges,499,100,,,fee schedule,Pays 100% Medicare OPPS,389.85,1201.73,
ARTHROSCOPIC CUTTER,7905712,CDM,272,RC,,,Outpatient,,,690,552,,586.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,140.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,389.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,389.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,389.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,389.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,621,90,,,percent of total billed charges,90% of total billed charges,241.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,474.03,68.7,,,percent of total billed charges,68.7% of total billed charges,552,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,400.2,58,,,percent of total billed charges,58% of total billed charges,140.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,586.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,140.55,621,
Incision and drainage of abscess; simple or single and complex or multiple,2010060,CDM,450,RC,10060,HCPCS,Outpatient,,,695,556,,590.75,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,141.57,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,392.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,392.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,392.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,392.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,164.53,102,,,fee schedule,Pays 102% Medicare OPPS,625.5,90,,,percent of total billed charges,90% of total billed charges,243.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,477.47,68.7,,,percent of total billed charges,68.7% of total billed charges,556,80,,,percent of total billed charges,80 percent of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,145.18,90,,,fee schedule,Pays 90% Medicare OPPS,403.1,58,,,percent of total billed charges,58% of total billed charges,141.57,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.83,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,590.75,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,141.57,625.5,
"I & D PILONIDAL CYST, SIMPLE",2010080,CDM,450,RC,,,Outpatient,,,695,556,,590.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,141.57,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,392.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,392.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,392.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,392.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,625.5,90,,,percent of total billed charges,90% of total billed charges,243.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,477.47,68.7,,,percent of total billed charges,68.7% of total billed charges,556,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,403.1,58,,,percent of total billed charges,58% of total billed charges,141.57,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,590.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,141.57,625.5,
LAC SIMPLE 7.6-12.5CM,2012004,CDM,450,RC,,,Outpatient,,,700,560,,595,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,142.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,395.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,395.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,395.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,395.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,630,90,,,percent of total billed charges,90% of total billed charges,245,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,480.9,68.7,,,percent of total billed charges,68.7% of total billed charges,560,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,406,58,,,percent of total billed charges,58% of total billed charges,142.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,595,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,142.59,630,
FACIAL LAC SIMPLE 7.6-12.5,2012015,CDM,450,RC,12015,HCPCS,Outpatient,,,700,560,,595,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,142.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,395.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,395.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,395.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,395.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,164.54,102,,,fee schedule,Pays 102% Medicare OPPS,630,90,,,percent of total billed charges,90% of total billed charges,245,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,480.9,68.7,,,percent of total billed charges,68.7% of total billed charges,560,80,,,percent of total billed charges,80 percent of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,145.18,90,,,fee schedule,Pays 90% Medicare OPPS,406,58,,,percent of total billed charges,58% of total billed charges,142.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.83,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,595,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,142.59,630,
ASPIRATION/OR INJECTION INTERMED JNT,2020605,CDM,450,RC,,,Outpatient,,,700,560,,595,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,142.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,395.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,395.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,395.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,395.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,630,90,,,percent of total billed charges,90% of total billed charges,245,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,480.9,68.7,,,percent of total billed charges,68.7% of total billed charges,560,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,406,58,,,percent of total billed charges,58% of total billed charges,142.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,595,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,142.59,630,
Draining or injecting medication into a large joint/bursa without ultrasound,4020605,CDM,320,RC,20605,HCPCS,Outpatient,,,700,560,,595,85,,,percent of total billed charges,85% of total billed charges,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,310.88,130,,,fee schedule,Pays 130% Medicare OPPS,142.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,395.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,395.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,395.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,393.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,239.38,102,,,fee schedule,Pays 102% Medicare OPPS,630,90,,,percent of total billed charges,90% of total billed charges,245,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,480.9,68.7,,,percent of total billed charges,68.7% of total billed charges,560,80,,,percent of total billed charges,80 percent of total billed charges,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,211.22,90,,,fee schedule,Pays 90% Medicare OPPS,406,58,,,percent of total billed charges,58% of total billed charges,142.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,239.14,100,,,fee schedule,Pays 100% Medicare OPPS,310.88,130,,,fee schedule,Pays 130% Medicare OPPS,595,85,,,percent of total billed charges,85% of total billed charges,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,142.59,630,
THORACENTESIS FOR ASPIRATION,4032421,CDM,324,RC,32555,HCPCS,Outpatient,,,700,560,,595,85,,,percent of total billed charges,85% of total billed charges,485.56,100,,,fee schedule,Pays 100% Medicare OPPS,485.56,100,,,fee schedule,Pays 100% Medicare OPPS,485.56,100,,,fee schedule,Pays 100% Medicare OPPS,661.48,130,,,fee schedule,Pays 130% Medicare OPPS,142.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,395.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,395.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,395.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,393.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,495.27,102,,,fee schedule,Pays 102% Medicare OPPS,630,90,,,percent of total billed charges,90% of total billed charges,245,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,480.9,68.7,,,percent of total billed charges,68.7% of total billed charges,560,80,,,percent of total billed charges,80 percent of total billed charges,485.56,100,,,fee schedule,Pays 100% Medicare OPPS,437,90,,,fee schedule,Pays 90% Medicare OPPS,406,58,,,percent of total billed charges,58% of total billed charges,142.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,508.83,100,,,fee schedule,Pays 100% Medicare OPPS,661.48,130,,,fee schedule,Pays 130% Medicare OPPS,595,85,,,percent of total billed charges,85% of total billed charges,485.56,100,,,fee schedule,Pays 100% Medicare OPPS,142.59,661.48,
THORACENTESIS W/ TUBE INSERT,4032422,CDM,324,RC,32555,HCPCS,Outpatient,,,700,560,,595,85,,,percent of total billed charges,85% of total billed charges,485.56,100,,,fee schedule,Pays 100% Medicare OPPS,485.56,100,,,fee schedule,Pays 100% Medicare OPPS,485.56,100,,,fee schedule,Pays 100% Medicare OPPS,661.48,130,,,fee schedule,Pays 130% Medicare OPPS,142.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,395.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,395.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,395.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,393.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,495.27,102,,,fee schedule,Pays 102% Medicare OPPS,630,90,,,percent of total billed charges,90% of total billed charges,245,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,480.9,68.7,,,percent of total billed charges,68.7% of total billed charges,560,80,,,percent of total billed charges,80 percent of total billed charges,485.56,100,,,fee schedule,Pays 100% Medicare OPPS,437,90,,,fee schedule,Pays 90% Medicare OPPS,406,58,,,percent of total billed charges,58% of total billed charges,142.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,508.83,100,,,fee schedule,Pays 100% Medicare OPPS,661.48,130,,,fee schedule,Pays 130% Medicare OPPS,595,85,,,percent of total billed charges,85% of total billed charges,485.56,100,,,fee schedule,Pays 100% Medicare OPPS,142.59,661.48,
US GUIDANCE CYS/ANY LOCATION,4600009,CDM,320,RC,76942,HCPCS,Outpatient,,,700,560,,595,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,142.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,395.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,395.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,395.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,393.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,630,90,,,percent of total billed charges,90% of total billed charges,245,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,480.9,68.7,,,percent of total billed charges,68.7% of total billed charges,560,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,406,58,,,percent of total billed charges,58% of total billed charges,142.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,595,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,142.59,630,
LENS ANTERIOR CHAMBER 19.0,1570029,CDM,276,RC,,,Outpatient,,,710,568,,603.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,144.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,639,90,,,percent of total billed charges,90% of total billed charges,248.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,487.77,68.7,,,percent of total billed charges,68.7% of total billed charges,568,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,411.8,58,,,percent of total billed charges,58% of total billed charges,144.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,603.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,639,
LENS ANTERIOR CHAMBER 15.5,1570117,CDM,276,RC,,,Outpatient,,,710,568,,603.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,144.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,639,90,,,percent of total billed charges,90% of total billed charges,248.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,487.77,68.7,,,percent of total billed charges,68.7% of total billed charges,568,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,411.8,58,,,percent of total billed charges,58% of total billed charges,144.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,603.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,639,
LENS ANTERIOR CHAMBER 17.5,1570118,CDM,276,RC,,,Outpatient,,,710,568,,603.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,144.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,639,90,,,percent of total billed charges,90% of total billed charges,248.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,487.77,68.7,,,percent of total billed charges,68.7% of total billed charges,568,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,411.8,58,,,percent of total billed charges,58% of total billed charges,144.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,603.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,639,
LENS ANTERIOR CHAMBER 16.0,1570119,CDM,276,RC,,,Outpatient,,,710,568,,603.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,144.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,639,90,,,percent of total billed charges,90% of total billed charges,248.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,487.77,68.7,,,percent of total billed charges,68.7% of total billed charges,568,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,411.8,58,,,percent of total billed charges,58% of total billed charges,144.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,603.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,639,
LENS ANTERIOR CHAMBER 20.0,1570121,CDM,276,RC,,,Outpatient,,,710,568,,603.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,144.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,639,90,,,percent of total billed charges,90% of total billed charges,248.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,487.77,68.7,,,percent of total billed charges,68.7% of total billed charges,568,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,411.8,58,,,percent of total billed charges,58% of total billed charges,144.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,603.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,639,
LENS ANTERIOR CHAMBER 13.0,1570122,CDM,276,RC,,,Outpatient,,,710,568,,603.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,144.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,639,90,,,percent of total billed charges,90% of total billed charges,248.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,487.77,68.7,,,percent of total billed charges,68.7% of total billed charges,568,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,411.8,58,,,percent of total billed charges,58% of total billed charges,144.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,603.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,639,
REMOVAL OF INGROWN TOENAIL,2011765,CDM,450,RC,11765,HCPCS,Outpatient,,,710,568,,603.5,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,144.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,401.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,401.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,401.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,401.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,316.7,102,,,fee schedule,Pays 102% Medicare OPPS,639,90,,,percent of total billed charges,90% of total billed charges,248.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,487.77,68.7,,,percent of total billed charges,68.7% of total billed charges,568,80,,,percent of total billed charges,80 percent of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,279.44,90,,,fee schedule,Pays 90% Medicare OPPS,411.8,58,,,percent of total billed charges,58% of total billed charges,144.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,328.14,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,603.5,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,144.63,639,
FACIAL LAC INTRM 2.6 - 5.0CM,2012052,CDM,450,RC,12052,HCPCS,Outpatient,,,710,568,,603.5,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,144.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,401.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,401.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,401.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,401.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,316.7,102,,,fee schedule,Pays 102% Medicare OPPS,639,90,,,percent of total billed charges,90% of total billed charges,248.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,487.77,68.7,,,percent of total billed charges,68.7% of total billed charges,568,80,,,percent of total billed charges,80 percent of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,279.44,90,,,fee schedule,Pays 90% Medicare OPPS,411.8,58,,,percent of total billed charges,58% of total billed charges,144.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,328.14,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,603.5,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,144.63,639,
DRAINAGE OF ABSCESS CYST,2041800,CDM,450,RC,41800,HCPCS,Outpatient,,,710,568,,603.5,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,144.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,401.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,401.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,401.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,401.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,639,90,,,percent of total billed charges,90% of total billed charges,248.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,487.77,68.7,,,percent of total billed charges,68.7% of total billed charges,568,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,411.8,58,,,percent of total billed charges,58% of total billed charges,144.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,603.5,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,639,
Fine Needle Aspiration Biopsy without imaging,4010021,CDM,320,RC,10021,HCPCS,Outpatient,,,710,568,,603.5,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,144.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,401.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,401.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,401.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,399.02,56.5,,,percent of total billed charges,56.5 percent of total billed charges,316.7,102,,,fee schedule,Pays 102% Medicare OPPS,639,90,,,percent of total billed charges,90% of total billed charges,248.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,487.77,68.7,,,percent of total billed charges,68.7% of total billed charges,568,80,,,percent of total billed charges,80 percent of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,279.44,90,,,fee schedule,Pays 90% Medicare OPPS,411.8,58,,,percent of total billed charges,58% of total billed charges,144.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,328.14,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,603.5,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,144.63,639,
XR CYSTOURETHROGRAM,4073070,CDM,320,RC,74455,HCPCS,Outpatient,,,710,568,,603.5,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,144.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,401.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,401.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,401.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,399.02,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,639,90,,,percent of total billed charges,90% of total billed charges,248.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,487.77,68.7,,,percent of total billed charges,68.7% of total billed charges,568,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,411.8,58,,,percent of total billed charges,58% of total billed charges,144.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,603.5,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,144.63,639,
XR HYSTERIOSALPINGOGRAM,4074740,CDM,320,RC,74740,HCPCS,Outpatient,,,710,568,,603.5,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,144.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,401.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,401.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,401.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,399.02,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,639,90,,,percent of total billed charges,90% of total billed charges,248.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,487.77,68.7,,,percent of total billed charges,68.7% of total billed charges,568,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,411.8,58,,,percent of total billed charges,58% of total billed charges,144.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,603.5,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,144.63,639,
SUPERPUBIC SET,7905885,CDM,270,RC,,,Outpatient,,,710,568,,603.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,144.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,401.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,401.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,401.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,401.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,639,90,,,percent of total billed charges,90% of total billed charges,248.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,487.77,68.7,,,percent of total billed charges,68.7% of total billed charges,568,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,411.8,58,,,percent of total billed charges,58% of total billed charges,144.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,603.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,144.63,639,
CATH CRE BALLOON 5838-05,1750017,CDM,270,RC,,,Outpatient,,,715,572,,607.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,145.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,403.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,403.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,403.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,403.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,643.5,90,,,percent of total billed charges,90% of total billed charges,250.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,491.21,68.7,,,percent of total billed charges,68.7% of total billed charges,572,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,414.7,58,,,percent of total billed charges,58% of total billed charges,145.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,607.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,145.65,643.5,
DREAMWIRE ST STIFF .035 260CM,1750030,CDM,272,RC,,,Outpatient,,,720,576,,612,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,146.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,648,90,,,percent of total billed charges,90% of total billed charges,252,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,494.64,68.7,,,percent of total billed charges,68.7% of total billed charges,576,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,417.6,58,,,percent of total billed charges,58% of total billed charges,146.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,612,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,146.66,648,
DREAMWIRE ANGLED .035 260CM,1750031,CDM,272,RC,,,Outpatient,,,720,576,,612,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,146.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,648,90,,,percent of total billed charges,90% of total billed charges,252,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,494.64,68.7,,,percent of total billed charges,68.7% of total billed charges,576,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,417.6,58,,,percent of total billed charges,58% of total billed charges,146.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,612,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,146.66,648,
DREAMWIRE ST STIFF .035 450CM,1750032,CDM,272,RC,,,Outpatient,,,720,576,,612,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,146.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,648,90,,,percent of total billed charges,90% of total billed charges,252,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,494.64,68.7,,,percent of total billed charges,68.7% of total billed charges,576,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,417.6,58,,,percent of total billed charges,58% of total billed charges,146.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,612,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,146.66,648,
Testing for presence of drug,3000119,CDM,301,RC,80307,HCPCS,Outpatient,,,720,576,,612,85,,,percent of total billed charges,85% of total billed charges,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,80.78,130,,,fee schedule,Pays 130% Medicare OPPS,73.62,120.37,,,fee schedule,120.37% of custom fee schedule,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,63.38,102,,,fee schedule,Pays 102% Medicare OPPS,648,90,,,percent of total billed charges,90% of total billed charges,76.56,125.18,,,fee schedule,125.18% of custom fee schedule,494.64,68.7,,,percent of total billed charges,68.7% of total billed charges,576,80,,,percent of total billed charges,80 percent of total billed charges,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,55.92,90,,,fee schedule,Pays 90% Medicare OPPS,417.6,58,,,percent of total billed charges,58% of total billed charges,73.62,120.37,,,fee schedule,120.37% of custom fee schedule,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,80.78,130,,,fee schedule,Pays 130% Medicare OPPS,612,85,,,percent of total billed charges,85% of total billed charges,62.14,100,,,fee schedule,Pays 100% Medicare OPPS,55.92,648,
3RD BK VIRUS QUANT PCR SERUM,3000650,CDM,301,RC,87799,HCPCS,Outpatient,,,720,576,,612,85,,,percent of total billed charges,85% of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,130,,,fee schedule,Pays 130% Medicare OPPS,146.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,43.69,102,,,fee schedule,Pays 102% Medicare OPPS,648,90,,,percent of total billed charges,90% of total billed charges,252,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,494.64,68.7,,,percent of total billed charges,68.7% of total billed charges,576,80,,,percent of total billed charges,80 percent of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,38.55,90,,,fee schedule,Pays 90% Medicare OPPS,417.6,58,,,percent of total billed charges,58% of total billed charges,146.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,130,,,fee schedule,Pays 130% Medicare OPPS,612,85,,,percent of total billed charges,85% of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,38.55,648,
3RD TPMT LEVEL,3000711,CDM,301,RC,80299,HCPCS,Outpatient,,,720,576,,612,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.01,102,,,fee schedule,Pays 102% Medicare OPPS,648,90,,,percent of total billed charges,90% of total billed charges,18.95,125.18,,,fee schedule,125.18% of custom fee schedule,494.64,68.7,,,percent of total billed charges,68.7% of total billed charges,576,80,,,percent of total billed charges,80 percent of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,90,,,fee schedule,Pays 90% Medicare OPPS,417.6,58,,,percent of total billed charges,58% of total billed charges,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,612,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,648,
N-TELOPEPTIDES (NTx) RANDOM URINE,3082523,CDM,301,RC,82523,HCPCS,Outpatient,,,720,576,,612,85,,,percent of total billed charges,85% of total billed charges,18.68,100,,,fee schedule,Pays 100% Medicare OPPS,18.68,100,,,fee schedule,Pays 100% Medicare OPPS,18.68,100,,,fee schedule,Pays 100% Medicare OPPS,24.28,130,,,fee schedule,Pays 130% Medicare OPPS,28.29,120.37,,,fee schedule,120.37% of custom fee schedule,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.05,102,,,fee schedule,Pays 102% Medicare OPPS,648,90,,,percent of total billed charges,90% of total billed charges,29.42,125.18,,,fee schedule,125.18% of custom fee schedule,494.64,68.7,,,percent of total billed charges,68.7% of total billed charges,576,80,,,percent of total billed charges,80 percent of total billed charges,18.68,100,,,fee schedule,Pays 100% Medicare OPPS,16.81,90,,,fee schedule,Pays 90% Medicare OPPS,417.6,58,,,percent of total billed charges,58% of total billed charges,28.29,120.37,,,fee schedule,120.37% of custom fee schedule,18.68,100,,,fee schedule,Pays 100% Medicare OPPS,24.28,130,,,fee schedule,Pays 130% Medicare OPPS,612,85,,,percent of total billed charges,85% of total billed charges,18.68,100,,,fee schedule,Pays 100% Medicare OPPS,16.81,648,
3RD BK VIRUS QUANT PCR URINE,3087799,CDM,301,RC,87799,HCPCS,Outpatient,,,720,576,,612,85,,,percent of total billed charges,85% of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,130,,,fee schedule,Pays 130% Medicare OPPS,146.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,43.69,102,,,fee schedule,Pays 102% Medicare OPPS,648,90,,,percent of total billed charges,90% of total billed charges,252,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,494.64,68.7,,,percent of total billed charges,68.7% of total billed charges,576,80,,,percent of total billed charges,80 percent of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,38.55,90,,,fee schedule,Pays 90% Medicare OPPS,417.6,58,,,percent of total billed charges,58% of total billed charges,146.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,130,,,fee schedule,Pays 130% Medicare OPPS,612,85,,,percent of total billed charges,85% of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,38.55,648,
MARLEX MESH 1 X 4,7905866,CDM,278,RC,,,Both,,,720,576,,612,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,146.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,648,90,,,percent of total billed charges,90% of total billed charges,252,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,494.64,68.7,,,percent of total billed charges,68.7% of total billed charges,576,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,417.6,58,,,percent of total billed charges,58% of total billed charges,146.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,612,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,648,
TROCAR XCEL BLADELESS B12LT,7950260,CDM,270,RC,,,Outpatient,,,720,576,,612,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,146.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,648,90,,,percent of total billed charges,90% of total billed charges,252,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,494.64,68.7,,,percent of total billed charges,68.7% of total billed charges,576,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,417.6,58,,,percent of total billed charges,58% of total billed charges,146.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,612,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,146.66,648,
TROCAR XCEL DILATING TIP D5LT,7950265,CDM,270,RC,,,Outpatient,,,720,576,,612,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,146.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,406.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,648,90,,,percent of total billed charges,90% of total billed charges,252,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,494.64,68.7,,,percent of total billed charges,68.7% of total billed charges,576,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,417.6,58,,,percent of total billed charges,58% of total billed charges,146.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,612,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,146.66,648,
"HYDROXYPROLINE, TOTAL",3083505,CDM,301,RC,83500,HCPCS,Outpatient,,,725,580,,616.25,85,,,percent of total billed charges,85% of total billed charges,22.65,100,,,fee schedule,Pays 100% Medicare OPPS,22.65,100,,,fee schedule,Pays 100% Medicare OPPS,22.65,100,,,fee schedule,Pays 100% Medicare OPPS,29.44,130,APC,,fee schedule,Pays 130% Medicare OPPS,34.29,120.37,,,fee schedule,120.37% of custom fee schedule,409.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,409.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,409.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,409.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,23.1,102,,,fee schedule,Pays 102% Medicare OPPS,652.5,90,,,percent of total billed charges,90% of total billed charges,35.66,125.18,,,fee schedule,125.18% of custom fee schedule,498.08,68.7,,,percent of total billed charges,68.7% of total billed charges,580,80,,,percent of total billed charges,80 percent of total billed charges,22.65,100,,,fee schedule,Pays 100% Medicare OPPS,20.38,90,,,fee schedule,Pays 90% Medicare OPPS,420.5,58,,,percent of total billed charges,58% of total billed charges,34.29,120.37,,,fee schedule,120.37% of custom fee schedule,22.65,100,,,fee schedule,Pays 100% Medicare OPPS,29.44,130,APC,,fee schedule,Pays 130% Medicare OPPS,616.25,85,,,percent of total billed charges,85% of total billed charges,22.65,100,,,fee schedule,Pays 100% Medicare OPPS,20.38,652.5,
BLOOD TYPE ANTIGEN DONOR,3086902,CDM,300,RC,86902,HCPCS,Outpatient,,,725,580,,616.25,85,,,percent of total billed charges,85% of total billed charges,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,370.6,130,,,fee schedule,Pays 130% Medicare OPPS,5.18,120.37,,,fee schedule,120.37% of custom fee schedule,409.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,409.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,409.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,409.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,266.86,102,,,fee schedule,Pays 102% Medicare OPPS,652.5,90,,,percent of total billed charges,90% of total billed charges,5.38,125.18,,,fee schedule,125.18% of custom fee schedule,498.08,68.7,,,percent of total billed charges,68.7% of total billed charges,580,80,,,percent of total billed charges,80 percent of total billed charges,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,235.46,90,,,fee schedule,Pays 90% Medicare OPPS,420.5,58,,,percent of total billed charges,58% of total billed charges,5.18,120.37,,,fee schedule,120.37% of custom fee schedule,285.08,100,,,fee schedule,Pays 100% Medicare OPPS,370.6,130,,,fee schedule,Pays 130% Medicare OPPS,616.25,85,,,percent of total billed charges,85% of total billed charges,261.63,100,,,fee schedule,Pays 100% Medicare OPPS,5.18,652.5,
RC ANTIBODY WORKUP,3186077,CDM,390,RC,86077,HCPCS,Outpatient,,,725,580,,616.25,85,,,percent of total billed charges,85% of total billed charges,22.19,100,,,fee schedule,Pays 100% Medicare OPPS,22.19,100,,,fee schedule,Pays 100% Medicare OPPS,22.19,100,,,fee schedule,Pays 100% Medicare OPPS,28.54,130,,,fee schedule,Pays 130% Medicare OPPS,54.17,120.37,,,fee schedule,120.37% of custom fee schedule,409.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,409.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,409.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,409.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,22.63,102,,,fee schedule,Pays 102% Medicare OPPS,652.5,90,,,percent of total billed charges,90% of total billed charges,56.33,125.18,,,fee schedule,125.18% of custom fee schedule,498.08,68.7,,,percent of total billed charges,68.7% of total billed charges,580,80,,,percent of total billed charges,80 percent of total billed charges,22.19,100,,,fee schedule,Pays 100% Medicare OPPS,19.97,90,,,fee schedule,Pays 90% Medicare OPPS,420.5,58,,,percent of total billed charges,58% of total billed charges,54.17,120.37,,,fee schedule,120.37% of custom fee schedule,21.95,100,,,fee schedule,Pays 100% Medicare OPPS,28.54,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,22.19,100,,,fee schedule,Pays 100% Medicare OPPS,19.97,652.5,
IMPLANT SMART PIN,7950126,CDM,270,RC,,,Outpatient,,,725,580,,616.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,147.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,409.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,409.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,409.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,409.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,652.5,90,,,percent of total billed charges,90% of total billed charges,253.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,498.08,68.7,,,percent of total billed charges,68.7% of total billed charges,580,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,420.5,58,,,percent of total billed charges,58% of total billed charges,147.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,616.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,147.68,652.5,
TROCAR ENDOPATH,7950164,CDM,270,RC,,,Outpatient,,,725,580,,616.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,147.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,409.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,409.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,409.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,409.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,652.5,90,,,percent of total billed charges,90% of total billed charges,253.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,498.08,68.7,,,percent of total billed charges,68.7% of total billed charges,580,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,420.5,58,,,percent of total billed charges,58% of total billed charges,147.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,616.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,147.68,652.5,
HERNIA PERFIX PLUG 0112760,1570010,CDM,278,RC,C1781,HCPCS,Both,,,735,588,,624.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,149.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,661.5,90,,,percent of total billed charges,90% of total billed charges,257.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,504.95,68.7,,,percent of total billed charges,68.7% of total billed charges,588,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,426.3,58,,,percent of total billed charges,58% of total billed charges,149.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,624.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,661.5,
SCREW 2.0MM X 9MM CANNULATED,1570068,CDM,278,RC,C1713,HCPCS,Both,,,735,588,,624.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,149.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,661.5,90,,,percent of total billed charges,90% of total billed charges,257.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,504.95,68.7,,,percent of total billed charges,68.7% of total billed charges,588,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,426.3,58,,,percent of total billed charges,58% of total billed charges,149.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,624.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,661.5,
SCREW 34MM 4.0 CANNULATED,1570070,CDM,278,RC,C1713,HCPCS,Both,,,735,588,,624.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,149.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,661.5,90,,,percent of total billed charges,90% of total billed charges,257.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,504.95,68.7,,,percent of total billed charges,68.7% of total billed charges,588,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,426.3,58,,,percent of total billed charges,58% of total billed charges,149.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,624.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,661.5,
SCREW 26MM 4.0 CANNULATED,1570071,CDM,278,RC,C1713,HCPCS,Both,,,735,588,,624.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,149.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,661.5,90,,,percent of total billed charges,90% of total billed charges,257.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,504.95,68.7,,,percent of total billed charges,68.7% of total billed charges,588,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,426.3,58,,,percent of total billed charges,58% of total billed charges,149.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,624.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,661.5,
HOOK/TRIANGLE BLADE PACK 3056,1570370,CDM,272,RC,,,Outpatient,,,735,588,,624.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,149.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,661.5,90,,,percent of total billed charges,90% of total billed charges,257.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,504.95,68.7,,,percent of total billed charges,68.7% of total billed charges,588,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,426.3,58,,,percent of total billed charges,58% of total billed charges,149.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,624.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,149.72,661.5,
MOLECULE ISOLATE NUCLEIC,3000330,CDM,300,RC,83891,HCPCS,Outpatient,,,735,588,,624.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,149.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,661.5,90,,,percent of total billed charges,90% of total billed charges,257.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,504.95,68.7,,,percent of total billed charges,68.7% of total billed charges,588,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,426.3,58,,,percent of total billed charges,58% of total billed charges,149.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,624.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,149.72,661.5,
MOLECULE NUCLEIC AMPLI,3000354,CDM,300,RC,81223,HCPCS,Outpatient,,,735,588,,624.75,85,,,percent of total billed charges,85% of total billed charges,499,100,,,fee schedule,Pays 100% Medicare OPPS,499,100,,,fee schedule,Pays 100% Medicare OPPS,499,100,,,fee schedule,Pays 100% Medicare OPPS,648.7,130,,,fee schedule,Pays 130% Medicare OPPS,1155.55,120.37,,,fee schedule,120.37% of custom fee schedule,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,508.98,102,,,fee schedule,Pays 102% Medicare OPPS,661.5,90,,,percent of total billed charges,90% of total billed charges,1201.73,125.18,,,fee schedule,125.18% of custom fee schedule,504.95,68.7,,,percent of total billed charges,68.7% of total billed charges,588,80,,,percent of total billed charges,80 percent of total billed charges,499,100,,,fee schedule,Pays 100% Medicare OPPS,449.1,90,,,fee schedule,Pays 90% Medicare OPPS,426.3,58,,,percent of total billed charges,58% of total billed charges,1155.55,120.37,,,fee schedule,120.37% of custom fee schedule,499,100,,,fee schedule,Pays 100% Medicare OPPS,648.7,130,,,fee schedule,Pays 130% Medicare OPPS,624.75,85,,,percent of total billed charges,85% of total billed charges,499,100,,,fee schedule,Pays 100% Medicare OPPS,415.28,1201.73,
MOLECULE DIAG,3000361,CDM,300,RC,83892,HCPCS,Outpatient,,,735,588,,624.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,149.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,661.5,90,,,percent of total billed charges,90% of total billed charges,257.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,504.95,68.7,,,percent of total billed charges,68.7% of total billed charges,588,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,426.3,58,,,percent of total billed charges,58% of total billed charges,149.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,624.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,149.72,661.5,
GALACTOSE-1- PHOSPHATE RBC LEVEL,3082760,CDM,300,RC,84378,HCPCS,Outpatient,,,735,588,,624.75,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,17.44,120.37,,,fee schedule,120.37% of custom fee schedule,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.76,102,,,fee schedule,Pays 102% Medicare OPPS,661.5,90,,,percent of total billed charges,90% of total billed charges,18.14,125.18,,,fee schedule,125.18% of custom fee schedule,504.95,68.7,,,percent of total billed charges,68.7% of total billed charges,588,80,,,percent of total billed charges,80 percent of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,90,,,fee schedule,Pays 90% Medicare OPPS,426.3,58,,,percent of total billed charges,58% of total billed charges,17.44,120.37,,,fee schedule,120.37% of custom fee schedule,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,,,fee schedule,Pays 130% Medicare OPPS,624.75,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,661.5,
KLEIHAUER BETKE,3085460,CDM,305,RC,85460,HCPCS,Outpatient,,,735,588,,624.75,85,,,percent of total billed charges,85% of total billed charges,7.73,100,,,fee schedule,Pays 100% Medicare OPPS,7.73,100,,,fee schedule,Pays 100% Medicare OPPS,7.73,100,,,fee schedule,Pays 100% Medicare OPPS,10.04,130,APC,,fee schedule,Pays 130% Medicare OPPS,3.66,120.37,,,fee schedule,120.37% of custom fee schedule,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,7.88,102,,,fee schedule,Pays 102% Medicare OPPS,661.5,90,,,percent of total billed charges,90% of total billed charges,3.81,125.18,,,fee schedule,125.18% of custom fee schedule,504.95,68.7,,,percent of total billed charges,68.7% of total billed charges,588,80,,,percent of total billed charges,80 percent of total billed charges,7.73,100,,,fee schedule,Pays 100% Medicare OPPS,6.95,90,,,fee schedule,Pays 90% Medicare OPPS,426.3,58,,,percent of total billed charges,58% of total billed charges,3.66,120.37,,,fee schedule,120.37% of custom fee schedule,7.73,100,,,fee schedule,Pays 100% Medicare OPPS,10.04,130,APC,,fee schedule,Pays 130% Medicare OPPS,624.75,85,,,percent of total billed charges,85% of total billed charges,7.73,100,,,fee schedule,Pays 100% Medicare OPPS,3.66,661.5,
Fetal biophysical profile with non-stress test,4676818,CDM,402,RC,76818,HCPCS,Outpatient,,,735,588,,624.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,149.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,413.07,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,661.5,90,,,percent of total billed charges,90% of total billed charges,257.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,504.95,68.7,,,percent of total billed charges,68.7% of total billed charges,588,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,426.3,58,,,percent of total billed charges,58% of total billed charges,149.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,624.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,661.5,
Fetal biophysical profile without non-stress test,4676819,CDM,402,RC,76819,HCPCS,Outpatient,,,735,588,,624.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,149.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,413.07,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,661.5,90,,,percent of total billed charges,90% of total billed charges,257.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,504.95,68.7,,,percent of total billed charges,68.7% of total billed charges,588,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,426.3,58,,,percent of total billed charges,58% of total billed charges,149.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,624.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,661.5,
US DOPPLER VELOCIMETRY FETAL UMBILICAL,4676820,CDM,402,RC,76820,HCPCS,Outpatient,,,735,588,,624.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,149.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,413.07,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,661.5,90,,,percent of total billed charges,90% of total billed charges,257.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,504.95,68.7,,,percent of total billed charges,68.7% of total billed charges,588,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,426.3,58,,,percent of total billed charges,58% of total billed charges,149.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,624.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,661.5,
HOLTER HOOK-UP W/SCAN,5693225,CDM,731,RC,93225,HCPCS,Outpatient,,,735,588,,624.75,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,149.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,415.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,661.5,90,,,percent of total billed charges,90% of total billed charges,257.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,504.95,68.7,,,percent of total billed charges,68.7% of total billed charges,588,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,426.3,58,,,percent of total billed charges,58% of total billed charges,149.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,624.75,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,661.5,
HERNIA MESH MED LEFT 3D MAX 0115310,1570061,CDM,278,RC,C1781,HCPCS,Both,,,740,592,,629,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,150.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,666,90,,,percent of total billed charges,90% of total billed charges,259,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,508.38,68.7,,,percent of total billed charges,68.7% of total billed charges,592,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,429.2,58,,,percent of total billed charges,58% of total billed charges,150.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,629,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,666,
HERNIA MESH MED RIGHT 3D MAX 0115320,1570063,CDM,278,RC,C1781,HCPCS,Both,,,740,592,,629,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,150.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,666,90,,,percent of total billed charges,90% of total billed charges,259,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,508.38,68.7,,,percent of total billed charges,68.7% of total billed charges,592,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,429.2,58,,,percent of total billed charges,58% of total billed charges,150.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,629,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,666,
LINEAR CUTTER 100 mm TLC10,7950228,CDM,270,RC,,,Outpatient,,,740,592,,629,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,150.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,418.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,418.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,418.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,418.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,666,90,,,percent of total billed charges,90% of total billed charges,259,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,508.38,68.7,,,percent of total billed charges,68.7% of total billed charges,592,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,429.2,58,,,percent of total billed charges,58% of total billed charges,150.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,629,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,150.74,666,
NEEDLE BIOPSY LIVER ADD ON,1547001,CDM,360,RC,47001,HCPCS,Outpatient,,,750,600,,637.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,152.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,,,,,other,Not reimbursable per contract,675,90,,,percent of total billed charges,90% of total billed charges,262.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,515.25,68.7,,,percent of total billed charges,68.7% of total billed charges,600,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,435,58,,,percent of total billed charges,58% of total billed charges,152.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,637.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,152.78,986.63,
DRAIN FINGER ABSESS SIMPLE,2026010,CDM,450,RC,26010,HCPCS,Outpatient,,,750,600,,637.5,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,152.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,164.53,102,,,fee schedule,Pays 102% Medicare OPPS,675,90,,,percent of total billed charges,90% of total billed charges,262.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,515.25,68.7,,,percent of total billed charges,68.7% of total billed charges,600,80,,,percent of total billed charges,80 percent of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,145.18,90,,,fee schedule,Pays 90% Medicare OPPS,435,58,,,percent of total billed charges,58% of total billed charges,152.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.83,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,637.5,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,145.18,675,
CL TX IP JT WITH MANIPULATION,2026775,CDM,450,RC,26775,HCPCS,Outpatient,,,750,600,,637.5,85,,,percent of total billed charges,85% of total billed charges,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,274.32,130,,,fee schedule,Pays 130% Medicare OPPS,152.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,221.03,102,,,fee schedule,Pays 102% Medicare OPPS,675,90,,,percent of total billed charges,90% of total billed charges,262.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,515.25,68.7,,,percent of total billed charges,68.7% of total billed charges,600,80,,,percent of total billed charges,80 percent of total billed charges,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,195.03,90,,,fee schedule,Pays 90% Medicare OPPS,435,58,,,percent of total billed charges,58% of total billed charges,152.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,211.02,100,,,fee schedule,Pays 100% Medicare OPPS,274.32,130,,,fee schedule,Pays 130% Medicare OPPS,637.5,85,,,percent of total billed charges,85% of total billed charges,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,152.78,675,
APPLY GAUNTLET CAST,2029085,CDM,450,RC,29085,HCPCS,Outpatient,,,750,600,,637.5,85,,,percent of total billed charges,85% of total billed charges,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,166.66,130,,,fee schedule,Pays 130% Medicare OPPS,152.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,129.44,102,,,fee schedule,Pays 102% Medicare OPPS,675,90,,,percent of total billed charges,90% of total billed charges,262.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,515.25,68.7,,,percent of total billed charges,68.7% of total billed charges,600,80,,,percent of total billed charges,80 percent of total billed charges,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,114.22,90,,,fee schedule,Pays 90% Medicare OPPS,435,58,,,percent of total billed charges,58% of total billed charges,152.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,128.19,100,,,fee schedule,Pays 100% Medicare OPPS,166.66,130,,,fee schedule,Pays 130% Medicare OPPS,637.5,85,,,percent of total billed charges,85% of total billed charges,126.91,100,,,fee schedule,Pays 100% Medicare OPPS,114.22,675,
REMOVAL REVISION OF CAST,2029700,CDM,450,RC,29700,HCPCS,Outpatient,,,750,600,,637.5,85,,,percent of total billed charges,85% of total billed charges,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,274.32,130,,,fee schedule,Pays 130% Medicare OPPS,152.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,221.03,102,,,fee schedule,Pays 102% Medicare OPPS,675,90,,,percent of total billed charges,90% of total billed charges,262.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,515.25,68.7,,,percent of total billed charges,68.7% of total billed charges,600,80,,,percent of total billed charges,80 percent of total billed charges,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,195.03,90,,,fee schedule,Pays 90% Medicare OPPS,435,58,,,percent of total billed charges,58% of total billed charges,152.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,211.02,100,,,fee schedule,Pays 100% Medicare OPPS,274.32,130,,,fee schedule,Pays 130% Medicare OPPS,637.5,85,,,percent of total billed charges,85% of total billed charges,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,152.78,675,
INS TEMP BLADDER CATH,2051705,CDM,450,RC,51702,HCPCS,Outpatient,,,750,600,,637.5,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,152.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,675,90,,,percent of total billed charges,90% of total billed charges,262.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,515.25,68.7,,,percent of total billed charges,68.7% of total billed charges,600,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,435,58,,,percent of total billed charges,58% of total billed charges,152.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,637.5,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,675,
I&D BARTHOLINS GLAND ABSCESS,2056420,CDM,450,RC,56420,HCPCS,Outpatient,,,750,600,,637.5,85,,,percent of total billed charges,85% of total billed charges,153.03,100,,,fee schedule,Pays 100% Medicare OPPS,153.03,100,,,fee schedule,Pays 100% Medicare OPPS,153.03,100,,,fee schedule,Pays 100% Medicare OPPS,203.67,130,,,fee schedule,Pays 130% Medicare OPPS,152.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,156.09,102,,,fee schedule,Pays 102% Medicare OPPS,675,90,,,percent of total billed charges,90% of total billed charges,262.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,515.25,68.7,,,percent of total billed charges,68.7% of total billed charges,600,80,,,percent of total billed charges,80 percent of total billed charges,153.03,100,,,fee schedule,Pays 100% Medicare OPPS,137.72,90,,,fee schedule,Pays 90% Medicare OPPS,435,58,,,percent of total billed charges,58% of total billed charges,152.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,156.68,100,,,fee schedule,Pays 100% Medicare OPPS,203.67,130,,,fee schedule,Pays 130% Medicare OPPS,637.5,85,,,percent of total billed charges,85% of total billed charges,153.03,100,,,fee schedule,Pays 100% Medicare OPPS,137.72,675,
UNLISTED PROCEDURE EXTERNAL EAR,2069399,CDM,450,RC,69399,HCPCS,Outpatient,,,750,600,,637.5,85,,,percent of total billed charges,85% of total billed charges,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,237.63,130,,,fee schedule,Pays 130% Medicare OPPS,152.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,193.85,102,,,fee schedule,Pays 102% Medicare OPPS,675,90,,,percent of total billed charges,90% of total billed charges,262.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,515.25,68.7,,,percent of total billed charges,68.7% of total billed charges,600,80,,,percent of total billed charges,80 percent of total billed charges,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,171.04,90,,,fee schedule,Pays 90% Medicare OPPS,435,58,,,percent of total billed charges,58% of total billed charges,152.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,182.8,100,,,fee schedule,Pays 100% Medicare OPPS,237.63,130,,,fee schedule,Pays 130% Medicare OPPS,637.5,85,,,percent of total billed charges,85% of total billed charges,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,152.78,675,
XR ASPIR FINE NDLE W IMAGE G,4010022,CDM,320,RC,10022,HCPCS,Outpatient,,,750,600,,637.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,152.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,421.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,675,90,,,percent of total billed charges,90% of total billed charges,262.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,515.25,68.7,,,percent of total billed charges,68.7% of total billed charges,600,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,435,58,,,percent of total billed charges,58% of total billed charges,152.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,637.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,152.78,675,
"Diagnostic ultrasound of an extremity excluding the bone, joints or vessels",4600007,CDM,402,RC,76882,HCPCS,Outpatient,,,750,600,,637.5,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,152.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,421.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,675,90,,,percent of total billed charges,90% of total billed charges,262.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,515.25,68.7,,,percent of total billed charges,68.7% of total billed charges,600,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,435,58,,,percent of total billed charges,58% of total billed charges,152.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,637.5,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,675,
"Diagnostic ultrasound of an extremity excluding the bone, joints or vessels",4676880,CDM,402,RC,76882,HCPCS,Outpatient,,,750,600,,637.5,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,152.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,421.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,675,90,,,percent of total billed charges,90% of total billed charges,262.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,515.25,68.7,,,percent of total billed charges,68.7% of total billed charges,600,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,435,58,,,percent of total billed charges,58% of total billed charges,152.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,637.5,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,675,
SOS BAKRI TAMP BALLOON,7950229,CDM,270,RC,,,Outpatient,,,750,600,,637.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,152.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,423.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,675,90,,,percent of total billed charges,90% of total billed charges,262.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,515.25,68.7,,,percent of total billed charges,68.7% of total billed charges,600,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,435,58,,,percent of total billed charges,58% of total billed charges,152.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,637.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,152.78,675,
LAC INTRM 12.6-20.0CM,2012035,CDM,450,RC,,,Outpatient,,,760,608,,646,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,154.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,684,90,,,percent of total billed charges,90% of total billed charges,266,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,522.12,68.7,,,percent of total billed charges,68.7% of total billed charges,608,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,440.8,58,,,percent of total billed charges,58% of total billed charges,154.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,646,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,154.81,684,
LUMBAR PUNCTURE,2062270,CDM,450,RC,,,Outpatient,,,760,608,,646,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,154.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,684,90,,,percent of total billed charges,90% of total billed charges,266,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,522.12,68.7,,,percent of total billed charges,68.7% of total billed charges,608,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,440.8,58,,,percent of total billed charges,58% of total billed charges,154.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,646,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,154.81,684,
ANTI MAG,3000015,CDM,301,RC,83520,HCPCS,Outpatient,,,760,608,,646,85,,,percent of total billed charges,85% of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,130,,,fee schedule,Pays 130% Medicare OPPS,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.61,102,,,fee schedule,Pays 102% Medicare OPPS,684,90,,,percent of total billed charges,90% of total billed charges,20.38,125.18,,,fee schedule,125.18% of custom fee schedule,522.12,68.7,,,percent of total billed charges,68.7% of total billed charges,608,80,,,percent of total billed charges,80 percent of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,15.54,90,,,fee schedule,Pays 90% Medicare OPPS,440.8,58,,,percent of total billed charges,58% of total billed charges,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,130,,,fee schedule,Pays 130% Medicare OPPS,646,85,,,percent of total billed charges,85% of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,15.54,684,
ROHIPNOL LEVEL,3000269,CDM,301,RC,80299,HCPCS,Outpatient,,,760,608,,646,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,19.01,102,,,fee schedule,Pays 102% Medicare OPPS,684,90,,,percent of total billed charges,90% of total billed charges,18.95,125.18,,,fee schedule,125.18% of custom fee schedule,522.12,68.7,,,percent of total billed charges,68.7% of total billed charges,608,80,,,percent of total billed charges,80 percent of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,90,,,fee schedule,Pays 90% Medicare OPPS,440.8,58,,,percent of total billed charges,58% of total billed charges,18.22,120.37,,,fee schedule,120.37% of custom fee schedule,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,24.23,130,,,fee schedule,Pays 130% Medicare OPPS,646,85,,,percent of total billed charges,85% of total billed charges,18.64,100,,,fee schedule,Pays 100% Medicare OPPS,16.77,684,
CATHARTIC SCREEN STOOL,3000292,CDM,301,RC,83735,HCPCS,Outpatient,,,760,608,,646,85,,,percent of total billed charges,85% of total billed charges,6.7,100,,,fee schedule,Pays 100% Medicare OPPS,6.7,100,,,fee schedule,Pays 100% Medicare OPPS,6.7,100,,,fee schedule,Pays 100% Medicare OPPS,8.71,130,,,fee schedule,Pays 130% Medicare OPPS,10.14,120.37,,,fee schedule,120.37% of custom fee schedule,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,6.83,102,,,fee schedule,Pays 102% Medicare OPPS,684,90,,,percent of total billed charges,90% of total billed charges,10.54,125.18,,,fee schedule,125.18% of custom fee schedule,522.12,68.7,,,percent of total billed charges,68.7% of total billed charges,608,80,,,percent of total billed charges,80 percent of total billed charges,6.7,100,,,fee schedule,Pays 100% Medicare OPPS,6.03,90,,,fee schedule,Pays 90% Medicare OPPS,440.8,58,,,percent of total billed charges,58% of total billed charges,10.14,120.37,,,fee schedule,120.37% of custom fee schedule,6.7,100,,,fee schedule,Pays 100% Medicare OPPS,8.71,130,,,fee schedule,Pays 130% Medicare OPPS,646,85,,,percent of total billed charges,85% of total billed charges,6.7,100,,,fee schedule,Pays 100% Medicare OPPS,6.03,684,
STREPTOCOCCUS PNEUMONIAE ANTIGENS URINE,3000628,CDM,302,RC,87899,HCPCS,Outpatient,,,760,608,,646,85,,,percent of total billed charges,85% of total billed charges,16.07,100,,,fee schedule,Pays 100% Medicare OPPS,16.07,100,,,fee schedule,Pays 100% Medicare OPPS,16.07,100,,,fee schedule,Pays 100% Medicare OPPS,20.89,130,,,fee schedule,Pays 130% Medicare OPPS,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,16.39,102,,,fee schedule,Pays 102% Medicare OPPS,684,90,,,percent of total billed charges,90% of total billed charges,18.88,125.18,,,fee schedule,125.18% of custom fee schedule,522.12,68.7,,,percent of total billed charges,68.7% of total billed charges,608,80,,,percent of total billed charges,80 percent of total billed charges,16.07,100,,,fee schedule,Pays 100% Medicare OPPS,14.46,90,,,fee schedule,Pays 90% Medicare OPPS,440.8,58,,,percent of total billed charges,58% of total billed charges,18.15,120.37,,,fee schedule,120.37% of custom fee schedule,16.07,100,,,fee schedule,Pays 100% Medicare OPPS,20.89,130,,,fee schedule,Pays 130% Medicare OPPS,646,85,,,percent of total billed charges,85% of total billed charges,16.07,100,,,fee schedule,Pays 100% Medicare OPPS,14.46,684,
....PHENOLP,3084311,CDM,301,RC,84311,HCPCS,Outpatient,,,760,608,,646,85,,,percent of total billed charges,85% of total billed charges,8.1,100,,,fee schedule,Pays 100% Medicare OPPS,8.1,100,,,fee schedule,Pays 100% Medicare OPPS,8.1,100,,,fee schedule,Pays 100% Medicare OPPS,10.53,130,APC,,fee schedule,Pays 130% Medicare OPPS,10.58,120.37,,,fee schedule,120.37% of custom fee schedule,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,8.26,102,,,fee schedule,Pays 102% Medicare OPPS,684,90,,,percent of total billed charges,90% of total billed charges,11,125.18,,,fee schedule,125.18% of custom fee schedule,522.12,68.7,,,percent of total billed charges,68.7% of total billed charges,608,80,,,percent of total billed charges,80 percent of total billed charges,8.1,100,,,fee schedule,Pays 100% Medicare OPPS,7.29,90,,,fee schedule,Pays 90% Medicare OPPS,440.8,58,,,percent of total billed charges,58% of total billed charges,10.58,120.37,,,fee schedule,120.37% of custom fee schedule,8.1,100,,,fee schedule,Pays 100% Medicare OPPS,10.53,130,APC,,fee schedule,Pays 130% Medicare OPPS,646,85,,,percent of total billed charges,85% of total billed charges,8.1,100,,,fee schedule,Pays 100% Medicare OPPS,7.29,684,
US ECHOENCEPHALOGRAPHY,4676506,CDM,402,RC,76506,HCPCS,Outpatient,,,760,608,,646,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,154.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,427.12,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,684,90,,,percent of total billed charges,90% of total billed charges,266,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,522.12,68.7,,,percent of total billed charges,68.7% of total billed charges,608,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,440.8,58,,,percent of total billed charges,58% of total billed charges,154.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,646,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,684,
ARTHROSCOPIC CUTTER,7905851,CDM,272,RC,,,Outpatient,,,760,608,,646,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,154.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,429.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,684,90,,,percent of total billed charges,90% of total billed charges,266,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,522.12,68.7,,,percent of total billed charges,68.7% of total billed charges,608,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,440.8,58,,,percent of total billed charges,58% of total billed charges,154.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,646,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,154.81,684,
REPLACE TRACEOTOMY TUBE,2031502,CDM,450,RC,31502,HCPCS,Outpatient,,,770,616,,654.5,85,,,percent of total billed charges,85% of total billed charges,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,237.63,130,,,fee schedule,Pays 130% Medicare OPPS,156.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,435.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,435.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,435.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,435.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,193.85,102,,,fee schedule,Pays 102% Medicare OPPS,693,90,,,percent of total billed charges,90% of total billed charges,269.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,528.99,68.7,,,percent of total billed charges,68.7% of total billed charges,616,80,,,percent of total billed charges,80 percent of total billed charges,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,171.04,90,,,fee schedule,Pays 90% Medicare OPPS,446.6,58,,,percent of total billed charges,58% of total billed charges,156.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,182.8,100,,,fee schedule,Pays 100% Medicare OPPS,237.63,130,,,fee schedule,Pays 130% Medicare OPPS,654.5,85,,,percent of total billed charges,85% of total billed charges,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,156.85,693,
US TRANSPLANT KIDNEY,4676776,CDM,402,RC,76776,HCPCS,Outpatient,,,770,616,,654.5,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,156.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,435.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,435.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,435.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,432.74,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,693,90,,,percent of total billed charges,90% of total billed charges,269.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,528.99,68.7,,,percent of total billed charges,68.7% of total billed charges,616,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,446.6,58,,,percent of total billed charges,58% of total billed charges,156.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,654.5,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,693,
STAPLER LOADING UNIT TA6035L,7950293,CDM,270,RC,,,Outpatient,,,780,624,,663,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,158.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,440.7,56.5,,,percent of total billed charges,56.5 percent of total billed charges,440.7,56.5,,,percent of total billed charges,56.5 percent of total billed charges,440.7,56.5,,,percent of total billed charges,56.5 percent of total billed charges,440.7,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,702,90,,,percent of total billed charges,90% of total billed charges,273,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,535.86,68.7,,,percent of total billed charges,68.7% of total billed charges,624,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,452.4,58,,,percent of total billed charges,58% of total billed charges,158.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,663,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,158.89,702,
HERNIA MESH LG LEFT 3D MAX 0115311,1570062,CDM,278,RC,C1781,HCPCS,Both,,,785,628,,667.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,159.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,706.5,90,,,percent of total billed charges,90% of total billed charges,274.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,539.3,68.7,,,percent of total billed charges,68.7% of total billed charges,628,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,455.3,58,,,percent of total billed charges,58% of total billed charges,159.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,667.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,706.5,
HERNIA MESH LARGE RIGHT 3D MAX 0115321,1570064,CDM,278,RC,C1781,HCPCS,Both,,,785,628,,667.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,159.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,706.5,90,,,percent of total billed charges,90% of total billed charges,274.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,539.3,68.7,,,percent of total billed charges,68.7% of total billed charges,628,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,455.3,58,,,percent of total billed charges,58% of total billed charges,159.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,667.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,706.5,
Draining or injecting medication into a major joint/bursa without ultrasound,2020610,CDM,450,RC,20610,HCPCS,Outpatient,,,785,628,,667.25,85,,,percent of total billed charges,85% of total billed charges,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,310.88,130,,,fee schedule,Pays 130% Medicare OPPS,159.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,239.38,102,,,fee schedule,Pays 102% Medicare OPPS,706.5,90,,,percent of total billed charges,90% of total billed charges,274.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,539.3,68.7,,,percent of total billed charges,68.7% of total billed charges,628,80,,,percent of total billed charges,80 percent of total billed charges,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,211.22,90,,,fee schedule,Pays 90% Medicare OPPS,455.3,58,,,percent of total billed charges,58% of total billed charges,159.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,239.14,100,,,fee schedule,Pays 100% Medicare OPPS,310.88,130,,,fee schedule,Pays 130% Medicare OPPS,667.25,85,,,percent of total billed charges,85% of total billed charges,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,159.9,706.5,
CL TX MC FX SGL MANIP EA BONE,2026600,CDM,450,RC,26600,HCPCS,Outpatient,,,785,628,,667.25,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,159.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,188.85,102,,,fee schedule,Pays 102% Medicare OPPS,706.5,90,,,percent of total billed charges,90% of total billed charges,274.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,539.3,68.7,,,percent of total billed charges,68.7% of total billed charges,628,80,,,percent of total billed charges,80 percent of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,166.63,90,,,fee schedule,Pays 90% Medicare OPPS,455.3,58,,,percent of total billed charges,58% of total billed charges,159.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,182.08,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,667.25,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,159.9,706.5,
NERVE BLK INJ TRIGEMINAL,2064400,CDM,450,RC,64400,HCPCS,Outpatient,,,785,628,,667.25,85,,,percent of total billed charges,85% of total billed charges,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,310.88,130,,,fee schedule,Pays 130% Medicare OPPS,159.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,239.38,102,,,fee schedule,Pays 102% Medicare OPPS,706.5,90,,,percent of total billed charges,90% of total billed charges,274.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,539.3,68.7,,,percent of total billed charges,68.7% of total billed charges,628,80,,,percent of total billed charges,80 percent of total billed charges,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,211.22,90,,,fee schedule,Pays 90% Medicare OPPS,455.3,58,,,percent of total billed charges,58% of total billed charges,159.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,239.14,100,,,fee schedule,Pays 100% Medicare OPPS,310.88,130,,,fee schedule,Pays 130% Medicare OPPS,667.25,85,,,percent of total billed charges,85% of total billed charges,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,159.9,706.5,
NERVE BLOCK other PERIPHE,2064450,CDM,450,RC,64450,HCPCS,Outpatient,,,785,628,,667.25,85,,,percent of total billed charges,85% of total billed charges,570.41,100,,,fee schedule,Pays 100% Medicare OPPS,570.41,100,,,fee schedule,Pays 100% Medicare OPPS,570.41,100,,,fee schedule,Pays 100% Medicare OPPS,736.77,130,,,fee schedule,Pays 130% Medicare OPPS,159.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,581.83,102,,,fee schedule,Pays 102% Medicare OPPS,706.5,90,,,percent of total billed charges,90% of total billed charges,274.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,539.3,68.7,,,percent of total billed charges,68.7% of total billed charges,628,80,,,percent of total billed charges,80 percent of total billed charges,570.41,100,,,fee schedule,Pays 100% Medicare OPPS,513.37,90,,,fee schedule,Pays 90% Medicare OPPS,455.3,58,,,percent of total billed charges,58% of total billed charges,159.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,566.74,100,,,fee schedule,Pays 100% Medicare OPPS,736.77,130,,,fee schedule,Pays 130% Medicare OPPS,667.25,85,,,percent of total billed charges,85% of total billed charges,570.41,100,,,fee schedule,Pays 100% Medicare OPPS,159.9,736.77,
Image of the heart to assess perfusion,4578478,CDM,341,RC,78452,HCPCS,Outpatient,,,785,628,,667.25,85,,,percent of total billed charges,85% of total billed charges,1173.9,100,,,fee schedule,Pays 100% Medicare OPPS,1173.9,100,,,fee schedule,Pays 100% Medicare OPPS,1173.9,100,,,fee schedule,Pays 100% Medicare OPPS,1517.67,130,,,fee schedule,Pays 130% Medicare OPPS,159.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1197.38,102,,,fee schedule,Pays 102% Medicare OPPS,706.5,90,,,percent of total billed charges,90% of total billed charges,274.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,539.3,68.7,,,percent of total billed charges,68.7% of total billed charges,628,80,,,percent of total billed charges,80 percent of total billed charges,1173.9,100,,,fee schedule,Pays 100% Medicare OPPS,1056.5,90,,,fee schedule,Pays 90% Medicare OPPS,455.3,58,,,percent of total billed charges,58% of total billed charges,159.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1167.44,100,,,fee schedule,Pays 100% Medicare OPPS,1517.67,130,,,fee schedule,Pays 130% Medicare OPPS,667.25,85,,,percent of total billed charges,85% of total billed charges,1173.9,100,,,fee schedule,Pays 100% Medicare OPPS,159.9,1517.67,
Ultrasound of head and neck,4600001,CDM,402,RC,76536,HCPCS,Outpatient,,,785,628,,667.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,159.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,441.17,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,706.5,90,,,percent of total billed charges,90% of total billed charges,274.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,539.3,68.7,,,percent of total billed charges,68.7% of total billed charges,628,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,455.3,58,,,percent of total billed charges,58% of total billed charges,159.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,667.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,706.5,
Ultrasound of head and neck,4600002,CDM,402,RC,76536,HCPCS,Outpatient,,,785,628,,667.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,159.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,441.17,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,706.5,90,,,percent of total billed charges,90% of total billed charges,274.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,539.3,68.7,,,percent of total billed charges,68.7% of total billed charges,628,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,455.3,58,,,percent of total billed charges,58% of total billed charges,159.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,667.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,706.5,
US PHYS EXT VENOUS/CMPLT-BIL,4693965,CDM,921,RC,93965,HCPCS,Outpatient,,,785,628,,667.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,159.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,443.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,706.5,90,,,percent of total billed charges,90% of total billed charges,274.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,539.3,68.7,,,percent of total billed charges,68.7% of total billed charges,628,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,455.3,58,,,percent of total billed charges,58% of total billed charges,159.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,667.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,159.9,706.5,
LAC SIMPLE 12.6-20.0CM,2012005,CDM,450,RC,12005,HCPCS,Outpatient,,,790,632,,671.5,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,160.92,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,446.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,446.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,446.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,446.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,316.7,102,,,fee schedule,Pays 102% Medicare OPPS,711,90,,,percent of total billed charges,90% of total billed charges,276.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,542.73,68.7,,,percent of total billed charges,68.7% of total billed charges,632,80,,,percent of total billed charges,80 percent of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,279.44,90,,,fee schedule,Pays 90% Medicare OPPS,458.2,58,,,percent of total billed charges,58% of total billed charges,160.92,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,328.14,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,671.5,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,160.92,711,
LAC CMPLX EA ADDTL 5 CMS,2013122,CDM,450,RC,13122,HCPCS,Outpatient,,,790,632,,671.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,160.92,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,446.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,446.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,446.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,446.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,711,90,,,percent of total billed charges,90% of total billed charges,276.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,542.73,68.7,,,percent of total billed charges,68.7% of total billed charges,632,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,458.2,58,,,percent of total billed charges,58% of total billed charges,160.92,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,671.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,160.92,711,
FB REMOVAL FOOT SUBCUT,2028190,CDM,450,RC,28190,HCPCS,Outpatient,,,790,632,,671.5,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,742.06,130,,,fee schedule,Pays 130% Medicare OPPS,160.92,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,446.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,446.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,446.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,446.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,570.17,102,,,fee schedule,Pays 102% Medicare OPPS,711,90,,,percent of total billed charges,90% of total billed charges,276.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,542.73,68.7,,,percent of total billed charges,68.7% of total billed charges,632,80,,,percent of total billed charges,80 percent of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,503.1,90,,,fee schedule,Pays 90% Medicare OPPS,458.2,58,,,percent of total billed charges,58% of total billed charges,160.92,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,570.82,100,,,fee schedule,Pays 100% Medicare OPPS,742.06,130,,,fee schedule,Pays 130% Medicare OPPS,671.5,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,160.92,742.06,
CIRCUMCISION SURG EXC NB,4054150,CDM,723,RC,54160,HCPCS,Outpatient,,,790,632,,671.5,85,,,percent of total billed charges,85% of total billed charges,516.79,100,,,fee schedule,Pays 100% Medicare OPPS,516.79,100,,,fee schedule,Pays 100% Medicare OPPS,516.79,100,,,fee schedule,Pays 100% Medicare OPPS,715.04,130,,,fee schedule,Pays 130% Medicare OPPS,160.92,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,446.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,446.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,446.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,446.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,527.14,102,,,fee schedule,Pays 102% Medicare OPPS,711,90,,,percent of total billed charges,90% of total billed charges,276.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,542.73,68.7,,,percent of total billed charges,68.7% of total billed charges,632,80,,,percent of total billed charges,80 percent of total billed charges,516.79,100,,,fee schedule,Pays 100% Medicare OPPS,465.12,90,,,fee schedule,Pays 90% Medicare OPPS,458.2,58,,,percent of total billed charges,58% of total billed charges,160.92,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,550.03,100,,,fee schedule,Pays 100% Medicare OPPS,715.04,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,516.79,100,,,fee schedule,Pays 100% Medicare OPPS,160.92,715.04,
ENDO CLIP 5 mm,7950114,CDM,270,RC,,,Outpatient,,,790,632,,671.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,160.92,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,446.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,446.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,446.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,446.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,711,90,,,percent of total billed charges,90% of total billed charges,276.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,542.73,68.7,,,percent of total billed charges,68.7% of total billed charges,632,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,458.2,58,,,percent of total billed charges,58% of total billed charges,160.92,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,671.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,160.92,711,
ENDO LIGACLIP AL326,7950155,CDM,270,RC,,,Outpatient,,,790,632,,671.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,160.92,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,446.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,446.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,446.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,446.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,711,90,,,percent of total billed charges,90% of total billed charges,276.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,542.73,68.7,,,percent of total billed charges,68.7% of total billed charges,632,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,458.2,58,,,percent of total billed charges,58% of total billed charges,160.92,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,671.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,160.92,711,
LENS INTRAOCULAR ZCB0018.5,1570200,CDM,276,RC,,,Outpatient,,,795,636,,675.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,161.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,715.5,90,,,percent of total billed charges,90% of total billed charges,278.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,546.17,68.7,,,percent of total billed charges,68.7% of total billed charges,636,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,461.1,58,,,percent of total billed charges,58% of total billed charges,161.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,675.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,715.5,
LENS INTRAOCULAR ZCB0020.5,1570201,CDM,276,RC,,,Outpatient,,,795,636,,675.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,161.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,715.5,90,,,percent of total billed charges,90% of total billed charges,278.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,546.17,68.7,,,percent of total billed charges,68.7% of total billed charges,636,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,461.1,58,,,percent of total billed charges,58% of total billed charges,161.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,675.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,715.5,
LENS INTRAOCULAR ZCB0021.0,1570202,CDM,276,RC,,,Outpatient,,,795,636,,675.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,161.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,715.5,90,,,percent of total billed charges,90% of total billed charges,278.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,546.17,68.7,,,percent of total billed charges,68.7% of total billed charges,636,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,461.1,58,,,percent of total billed charges,58% of total billed charges,161.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,675.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,715.5,
LENS INTRAOCULAR ZCB0021.5,1570203,CDM,276,RC,,,Outpatient,,,795,636,,675.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,161.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,715.5,90,,,percent of total billed charges,90% of total billed charges,278.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,546.17,68.7,,,percent of total billed charges,68.7% of total billed charges,636,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,461.1,58,,,percent of total billed charges,58% of total billed charges,161.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,675.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,715.5,
LENS INTRAOCULAR ZCB0023.0,1570204,CDM,276,RC,,,Outpatient,,,795,636,,675.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,161.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,715.5,90,,,percent of total billed charges,90% of total billed charges,278.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,546.17,68.7,,,percent of total billed charges,68.7% of total billed charges,636,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,461.1,58,,,percent of total billed charges,58% of total billed charges,161.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,675.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,715.5,
FLOVENT (FLUTICASONE) 110MCG MDI,2600054,CDM,637,RC,,,Outpatient,,,795,636,,675.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,161.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,449.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,449.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,449.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,449.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,715.5,90,,,percent of total billed charges,90% of total billed charges,278.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,546.17,68.7,,,percent of total billed charges,68.7% of total billed charges,636,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,461.1,58,,,percent of total billed charges,58% of total billed charges,161.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,675.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,161.94,715.5,
LOVENOX (ENOXAPARIN) INJ 150MG,2601423,CDM,636,RC,J1650,HCPCS,Both,,,795,636,,675.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,161.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,414.76,52.17,,,case rate,100% of BCBS case rate,414.76,52.17,,,case rate,100% of BCBS case rate,414.76,52.17,,,case rate,100% of BCBS case rate,414.76,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,715.5,90,,,percent of total billed charges,90% of total billed charges,278.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,546.17,68.7,,,percent of total billed charges,68.7% of total billed charges,636,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,461.1,58,,,percent of total billed charges,58% of total billed charges,161.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,675.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,161.94,715.5,
AZMACORT (TRIAMCINOLONE) INH :,2605066,CDM,250,RC,J7684,HCPCS,Outpatient,,,795,636,,675.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,161.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,449.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,449.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,449.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,449.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,715.5,90,,,percent of total billed charges,90% of total billed charges,278.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,546.17,68.7,,,percent of total billed charges,68.7% of total billed charges,636,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,461.1,58,,,percent of total billed charges,58% of total billed charges,161.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,675.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,161.94,715.5,
GALACTOSE 1-PHOSPHATE URIDYLTRANSFERASE,3000231,CDM,301,RC,82775,HCPCS,Outpatient,,,795,636,,675.75,85,,,percent of total billed charges,85% of total billed charges,21.07,100,,,fee schedule,Pays 100% Medicare OPPS,21.07,100,,,fee schedule,Pays 100% Medicare OPPS,21.07,100,,,fee schedule,Pays 100% Medicare OPPS,27.39,130,,,fee schedule,Pays 130% Medicare OPPS,31.89,120.37,,,fee schedule,120.37% of custom fee schedule,449.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,449.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,449.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,449.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,21.49,102,,,fee schedule,Pays 102% Medicare OPPS,715.5,90,,,percent of total billed charges,90% of total billed charges,33.16,125.18,,,fee schedule,125.18% of custom fee schedule,546.17,68.7,,,percent of total billed charges,68.7% of total billed charges,636,80,,,percent of total billed charges,80 percent of total billed charges,21.07,100,,,fee schedule,Pays 100% Medicare OPPS,18.96,90,,,fee schedule,Pays 90% Medicare OPPS,461.1,58,,,percent of total billed charges,58% of total billed charges,31.89,120.37,,,fee schedule,120.37% of custom fee schedule,21.07,100,,,fee schedule,Pays 100% Medicare OPPS,27.39,130,,,fee schedule,Pays 130% Medicare OPPS,675.75,85,,,percent of total billed charges,85% of total billed charges,21.07,100,,,fee schedule,Pays 100% Medicare OPPS,18.96,715.5,
3RD HEPATITIS D VIRUS IGM AB,3000629,CDM,301,RC,86692,HCPCS,Outpatient,,,795,636,,675.75,85,,,percent of total billed charges,85% of total billed charges,17.16,100,,,fee schedule,Pays 100% Medicare OPPS,17.16,100,,,fee schedule,Pays 100% Medicare OPPS,17.16,100,,,fee schedule,Pays 100% Medicare OPPS,22.3,130,APC,,fee schedule,Pays 130% Medicare OPPS,25.98,120.37,,,fee schedule,120.37% of custom fee schedule,449.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,449.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,449.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,449.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.5,102,,,fee schedule,Pays 102% Medicare OPPS,715.5,90,,,percent of total billed charges,90% of total billed charges,27.01,125.18,,,fee schedule,125.18% of custom fee schedule,546.17,68.7,,,percent of total billed charges,68.7% of total billed charges,636,80,,,percent of total billed charges,80 percent of total billed charges,17.16,100,,,fee schedule,Pays 100% Medicare OPPS,15.44,90,,,fee schedule,Pays 90% Medicare OPPS,461.1,58,,,percent of total billed charges,58% of total billed charges,25.98,120.37,,,fee schedule,120.37% of custom fee schedule,17.16,100,,,fee schedule,Pays 100% Medicare OPPS,22.3,130,APC,,fee schedule,Pays 130% Medicare OPPS,675.75,85,,,percent of total billed charges,85% of total billed charges,17.16,100,,,fee schedule,Pays 100% Medicare OPPS,15.44,715.5,
POS AIRWAY PRESSURE CPAP,5594660,CDM,460,RC,94660,HCPCS,Outpatient,,,795,636,,675.75,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,161.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,449.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,449.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,449.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,449.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,172.23,102,,,fee schedule,Pays 102% Medicare OPPS,715.5,90,,,percent of total billed charges,90% of total billed charges,278.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,546.17,68.7,,,percent of total billed charges,68.7% of total billed charges,636,80,,,percent of total billed charges,80 percent of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,151.96,90,,,fee schedule,Pays 90% Medicare OPPS,461.1,58,,,percent of total billed charges,58% of total billed charges,161.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,168.43,100,,,fee schedule,Pays 100% Medicare OPPS,218.97,130,,,fee schedule,Pays 130% Medicare OPPS,675.75,85,,,percent of total billed charges,85% of total billed charges,168.85,100,,,fee schedule,Pays 100% Medicare OPPS,151.96,715.5,
ACELLULAR DERM MATRIX IMPLT,1515777,CDM,360,RC,15777,HCPCS,Outpatient,,,800,640,,680,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,162.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,,,,,other,Not reimbursable per contract,720,90,,,percent of total billed charges,90% of total billed charges,280,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,549.6,68.7,,,percent of total billed charges,68.7% of total billed charges,640,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,464,58,,,percent of total billed charges,58% of total billed charges,162.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,680,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,162.96,986.63,
TOXOCARA TITER,3086682,CDM,302,RC,86682,HCPCS,Outpatient,,,800,640,,680,85,,,percent of total billed charges,85% of total billed charges,13.01,100,,,fee schedule,Pays 100% Medicare OPPS,13.01,100,,,fee schedule,Pays 100% Medicare OPPS,13.01,100,,,fee schedule,Pays 100% Medicare OPPS,16.91,130,APC,,fee schedule,Pays 130% Medicare OPPS,19.68,120.37,,,fee schedule,120.37% of custom fee schedule,452,56.5,,,percent of total billed charges,56.5 percent of total billed charges,452,56.5,,,percent of total billed charges,56.5 percent of total billed charges,452,56.5,,,percent of total billed charges,56.5 percent of total billed charges,452,56.5,,,percent of total billed charges,56.5 percent of total billed charges,13.27,102,,,fee schedule,Pays 102% Medicare OPPS,720,90,,,percent of total billed charges,90% of total billed charges,20.47,125.18,,,fee schedule,125.18% of custom fee schedule,549.6,68.7,,,percent of total billed charges,68.7% of total billed charges,640,80,,,percent of total billed charges,80 percent of total billed charges,13.01,100,,,fee schedule,Pays 100% Medicare OPPS,11.7,90,,,fee schedule,Pays 90% Medicare OPPS,464,58,,,percent of total billed charges,58% of total billed charges,19.68,120.37,,,fee schedule,120.37% of custom fee schedule,13.01,100,,,fee schedule,Pays 100% Medicare OPPS,16.91,130,APC,,fee schedule,Pays 130% Medicare OPPS,680,85,,,percent of total billed charges,85% of total billed charges,13.01,100,,,fee schedule,Pays 100% Medicare OPPS,11.7,720,
XR SPINE/CER SP WITH FLEX & EXT,4072052,CDM,320,RC,72052,HCPCS,Outpatient,,,800,640,,680,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,162.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,452,56.5,,,percent of total billed charges,56.5 percent of total billed charges,452,56.5,,,percent of total billed charges,56.5 percent of total billed charges,452,56.5,,,percent of total billed charges,56.5 percent of total billed charges,449.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,720,90,,,percent of total billed charges,90% of total billed charges,280,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,549.6,68.7,,,percent of total billed charges,68.7% of total billed charges,640,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,464,58,,,percent of total billed charges,58% of total billed charges,162.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,680,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,720,
XR SMALL BOWEL,4074250,CDM,320,RC,74250,HCPCS,Outpatient,,,800,640,,680,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.21,130,,,fee schedule,Pays 130% Medicare OPPS,162.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,452,56.5,,,percent of total billed charges,56.5 percent of total billed charges,452,56.5,,,percent of total billed charges,56.5 percent of total billed charges,452,56.5,,,percent of total billed charges,56.5 percent of total billed charges,449.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.67,102,,,fee schedule,Pays 102% Medicare OPPS,720,90,,,percent of total billed charges,90% of total billed charges,280,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,549.6,68.7,,,percent of total billed charges,68.7% of total billed charges,640,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,464,58,,,percent of total billed charges,58% of total billed charges,162.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.21,130,,,fee schedule,Pays 130% Medicare OPPS,680,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,720,
SCREW 4.0 LOCKING OSTEOPENIA 10MM,1570036,CDM,278,RC,C1713,HCPCS,Both,,,810,648,,688.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,165,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,729,90,,,percent of total billed charges,90% of total billed charges,283.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,556.47,68.7,,,percent of total billed charges,68.7% of total billed charges,648,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,469.8,58,,,percent of total billed charges,58% of total billed charges,165,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,688.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,729,
SCREW 4.0 LOCKING OSTEOPENIA 12MM,1570037,CDM,278,RC,C1713,HCPCS,Both,,,810,648,,688.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,165,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,729,90,,,percent of total billed charges,90% of total billed charges,283.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,556.47,68.7,,,percent of total billed charges,68.7% of total billed charges,648,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,469.8,58,,,percent of total billed charges,58% of total billed charges,165,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,688.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,729,
SCREW 4.0 LOCKING OSTEOPENIA 14MM,1570038,CDM,278,RC,C1713,HCPCS,Both,,,810,648,,688.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,165,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,729,90,,,percent of total billed charges,90% of total billed charges,283.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,556.47,68.7,,,percent of total billed charges,68.7% of total billed charges,648,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,469.8,58,,,percent of total billed charges,58% of total billed charges,165,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,688.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,729,
SCREW 4.0 LOCKING OSTEOPENIA 16MM,1570039,CDM,278,RC,C1713,HCPCS,Both,,,810,648,,688.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,165,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,729,90,,,percent of total billed charges,90% of total billed charges,283.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,556.47,68.7,,,percent of total billed charges,68.7% of total billed charges,648,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,469.8,58,,,percent of total billed charges,58% of total billed charges,165,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,688.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,729,
NEEDLE SCORPION MULTIFIRE,1570816,CDM,272,RC,,,Outpatient,,,810,648,,688.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,165,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,457.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,457.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,457.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,457.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,729,90,,,percent of total billed charges,90% of total billed charges,283.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,556.47,68.7,,,percent of total billed charges,68.7% of total billed charges,648,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,469.8,58,,,percent of total billed charges,58% of total billed charges,165,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,688.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,165,729,
GASTROSTOMY TUBE REPLACE,2043760,CDM,450,RC,43762,HCPCS,Outpatient,,,810,648,,688.5,85,,,percent of total billed charges,85% of total billed charges,239.04,100,,,fee schedule,Pays 100% Medicare OPPS,239.04,100,,,fee schedule,Pays 100% Medicare OPPS,239.04,100,,,fee schedule,Pays 100% Medicare OPPS,245.69,130,,,fee schedule,Pays 130% Medicare OPPS,165,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,457.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,457.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,457.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,457.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,243.81,102,,,fee schedule,Pays 102% Medicare OPPS,729,90,,,percent of total billed charges,90% of total billed charges,283.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,556.47,68.7,,,percent of total billed charges,68.7% of total billed charges,648,80,,,percent of total billed charges,80 percent of total billed charges,239.04,100,,,fee schedule,Pays 100% Medicare OPPS,215.13,90,,,fee schedule,Pays 90% Medicare OPPS,469.8,58,,,percent of total billed charges,58% of total billed charges,165,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,188.99,100,,,fee schedule,Pays 100% Medicare OPPS,245.69,130,,,fee schedule,Pays 130% Medicare OPPS,688.5,85,,,percent of total billed charges,85% of total billed charges,239.04,100,,,fee schedule,Pays 100% Medicare OPPS,165,729,
HERNIA PERFIX PLUG 0112780,1570012,CDM,278,RC,C1781,HCPCS,Both,,,815,652,,692.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,166.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,733.5,90,,,percent of total billed charges,90% of total billed charges,285.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,559.91,68.7,,,percent of total billed charges,68.7% of total billed charges,652,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,472.7,58,,,percent of total billed charges,58% of total billed charges,166.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,692.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,733.5,
FOLEY CATH INSERTION SIMP,2051702,CDM,450,RC,51702,HCPCS,Outpatient,,,815,652,,692.75,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,166.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,460.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,460.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,460.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,460.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,733.5,90,,,percent of total billed charges,90% of total billed charges,285.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,559.91,68.7,,,percent of total billed charges,68.7% of total billed charges,652,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,472.7,58,,,percent of total billed charges,58% of total billed charges,166.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,692.75,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,733.5,
ZYVOX (LINEZOLID) IVPB 600MG/300ML,2601419,CDM,636,RC,J2020,HCPCS,Both,,,815,652,,692.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,5.04,120.37,,,fee schedule,120.37% of custom fee schedule,425.19,52.17,,,case rate,100% of BCBS case rate,425.19,52.17,,,case rate,100% of BCBS case rate,425.19,52.17,,,case rate,100% of BCBS case rate,425.19,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,733.5,90,,,percent of total billed charges,90% of total billed charges,5.25,125.18,,,fee schedule,125.18% of custom fee schedule,559.91,68.7,,,percent of total billed charges,68.7% of total billed charges,652,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,472.7,58,,,percent of total billed charges,58% of total billed charges,5.04,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,692.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5.04,733.5,
IN & OUT CATHETERIZATION,4051701,CDM,762,RC,51701,HCPCS,Outpatient,,,815,652,,692.75,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,166.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,460.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,460.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,460.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,460.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,733.5,90,,,percent of total billed charges,90% of total billed charges,285.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,559.91,68.7,,,percent of total billed charges,68.7% of total billed charges,652,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,472.7,58,,,percent of total billed charges,58% of total billed charges,166.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,692.75,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,733.5,
NM PARATHYROID,4578070,CDM,341,RC,78070,HCPCS,Outpatient,,,815,652,,692.75,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,166.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,460.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,460.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,460.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,460.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,345.39,102,,,fee schedule,Pays 102% Medicare OPPS,733.5,90,,,percent of total billed charges,90% of total billed charges,285.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,559.91,68.7,,,percent of total billed charges,68.7% of total billed charges,652,80,,,percent of total billed charges,80 percent of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,304.76,90,,,fee schedule,Pays 90% Medicare OPPS,472.7,58,,,percent of total billed charges,58% of total billed charges,166.02,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,341.87,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,692.75,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,166.02,733.5,
OR ACUITY LEVEL III X 15 MIN,1501154,CDM,360,RC,,,Outpatient,,,820,656,,697,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,167.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,738,90,,,percent of total billed charges,90% of total billed charges,287,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,563.34,68.7,,,percent of total billed charges,68.7% of total billed charges,656,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,475.6,58,,,percent of total billed charges,58% of total billed charges,167.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,697,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,167.03,738,
CATH CRE BALLOON 5838,1750003,CDM,272,RC,,,Outpatient,,,820,656,,697,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,167.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,738,90,,,percent of total billed charges,90% of total billed charges,287,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,563.34,68.7,,,percent of total billed charges,68.7% of total billed charges,656,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,475.6,58,,,percent of total billed charges,58% of total billed charges,167.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,697,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,167.03,738,
CATH CRE BALLOON 5837,1750004,CDM,272,RC,,,Outpatient,,,820,656,,697,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,167.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,738,90,,,percent of total billed charges,90% of total billed charges,287,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,563.34,68.7,,,percent of total billed charges,68.7% of total billed charges,656,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,475.6,58,,,percent of total billed charges,58% of total billed charges,167.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,697,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,167.03,738,
CATH CRE BALLOON 5836,1750012,CDM,272,RC,,,Outpatient,,,820,656,,697,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,167.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,738,90,,,percent of total billed charges,90% of total billed charges,287,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,563.34,68.7,,,percent of total billed charges,68.7% of total billed charges,656,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,475.6,58,,,percent of total billed charges,58% of total billed charges,167.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,697,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,167.03,738,
CATH CRE BALLOON 5834,1750068,CDM,272,RC,,,Outpatient,,,820,656,,697,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,167.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,738,90,,,percent of total billed charges,90% of total billed charges,287,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,563.34,68.7,,,percent of total billed charges,68.7% of total billed charges,656,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,475.6,58,,,percent of total billed charges,58% of total billed charges,167.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,697,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,167.03,738,
3RD HIV VIRAL LOAD,3000153,CDM,306,RC,87536,HCPCS,Outpatient,,,820,656,,697,85,,,percent of total billed charges,85% of total billed charges,85.1,100,,,fee schedule,Pays 100% Medicare OPPS,85.1,100,,,fee schedule,Pays 100% Medicare OPPS,85.1,100,,,fee schedule,Pays 100% Medicare OPPS,110.63,130,,,fee schedule,Pays 130% Medicare OPPS,68.01,120.37,,,fee schedule,120.37% of custom fee schedule,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,86.8,102,,,fee schedule,Pays 102% Medicare OPPS,738,90,,,percent of total billed charges,90% of total billed charges,70.73,125.18,,,fee schedule,125.18% of custom fee schedule,563.34,68.7,,,percent of total billed charges,68.7% of total billed charges,656,80,,,percent of total billed charges,80 percent of total billed charges,85.1,100,,,fee schedule,Pays 100% Medicare OPPS,76.58,90,,,fee schedule,Pays 90% Medicare OPPS,475.6,58,,,percent of total billed charges,58% of total billed charges,68.01,120.37,,,fee schedule,120.37% of custom fee schedule,85.1,100,,,fee schedule,Pays 100% Medicare OPPS,110.63,130,,,fee schedule,Pays 130% Medicare OPPS,697,85,,,percent of total billed charges,85% of total billed charges,85.1,100,,,fee schedule,Pays 100% Medicare OPPS,68.01,738,
HIV DNA BY PRC,3087535,CDM,300,RC,87535,HCPCS,Outpatient,,,820,656,,697,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,,,fee schedule,Pays 130% Medicare OPPS,29.7,120.37,,,fee schedule,120.37% of custom fee schedule,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,35.79,102,,,fee schedule,Pays 102% Medicare OPPS,738,90,,,percent of total billed charges,90% of total billed charges,30.88,125.18,,,fee schedule,125.18% of custom fee schedule,563.34,68.7,,,percent of total billed charges,68.7% of total billed charges,656,80,,,percent of total billed charges,80 percent of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,31.58,90,,,fee schedule,Pays 90% Medicare OPPS,475.6,58,,,percent of total billed charges,58% of total billed charges,29.7,120.37,,,fee schedule,120.37% of custom fee schedule,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,,,fee schedule,Pays 130% Medicare OPPS,697,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,29.7,738,
3RD HIV RNA BY PCR,3087536,CDM,306,RC,87536,HCPCS,Outpatient,,,820,656,,697,85,,,percent of total billed charges,85% of total billed charges,85.1,100,,,fee schedule,Pays 100% Medicare OPPS,85.1,100,,,fee schedule,Pays 100% Medicare OPPS,85.1,100,,,fee schedule,Pays 100% Medicare OPPS,110.63,130,,,fee schedule,Pays 130% Medicare OPPS,68.01,120.37,,,fee schedule,120.37% of custom fee schedule,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,86.8,102,,,fee schedule,Pays 102% Medicare OPPS,738,90,,,percent of total billed charges,90% of total billed charges,70.73,125.18,,,fee schedule,125.18% of custom fee schedule,563.34,68.7,,,percent of total billed charges,68.7% of total billed charges,656,80,,,percent of total billed charges,80 percent of total billed charges,85.1,100,,,fee schedule,Pays 100% Medicare OPPS,76.58,90,,,fee schedule,Pays 90% Medicare OPPS,475.6,58,,,percent of total billed charges,58% of total billed charges,68.01,120.37,,,fee schedule,120.37% of custom fee schedule,85.1,100,,,fee schedule,Pays 100% Medicare OPPS,110.63,130,,,fee schedule,Pays 130% Medicare OPPS,697,85,,,percent of total billed charges,85% of total billed charges,85.1,100,,,fee schedule,Pays 100% Medicare OPPS,68.01,738,
XR OPER CHOLANGI 2ND SET FILMS,4074301,CDM,320,RC,74301,HCPCS,Outpatient,,,820,656,,697,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,167.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,460.84,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,738,90,,,percent of total billed charges,90% of total billed charges,287,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,563.34,68.7,,,percent of total billed charges,68.7% of total billed charges,656,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,475.6,58,,,percent of total billed charges,58% of total billed charges,167.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,697,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,167.03,738,
XR GASTRIC TUBE INJECTION,4076080,CDM,320,RC,49465,HCPCS,Outpatient,,,820,656,,697,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,167.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,460.84,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,738,90,,,percent of total billed charges,90% of total billed charges,287,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,563.34,68.7,,,percent of total billed charges,68.7% of total billed charges,656,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,475.6,58,,,percent of total billed charges,58% of total billed charges,167.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,697,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,167.03,738,
NM TC99M CARDIOLITE,4500013,CDM,343,RC,A9500,HCPCS,Outpatient,,,820,656,,697,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,167.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,463.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,738,90,,,percent of total billed charges,90% of total billed charges,287,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,563.34,68.7,,,percent of total billed charges,68.7% of total billed charges,656,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,475.6,58,,,percent of total billed charges,58% of total billed charges,167.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,697,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,167.03,738,
RESOLUTION CLIP M00522610,1750015,CDM,272,RC,,,Outpatient,,,835,668,,709.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,170.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,471.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,471.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,471.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,471.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,751.5,90,,,percent of total billed charges,90% of total billed charges,292.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,573.65,68.7,,,percent of total billed charges,68.7% of total billed charges,668,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,484.3,58,,,percent of total billed charges,58% of total billed charges,170.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,709.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,170.09,751.5,
RESOLUTION CLIP M00522611,1750019,CDM,272,RC,,,Outpatient,,,835,668,,709.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,170.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,471.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,471.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,471.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,471.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,751.5,90,,,percent of total billed charges,90% of total billed charges,292.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,573.65,68.7,,,percent of total billed charges,68.7% of total billed charges,668,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,484.3,58,,,percent of total billed charges,58% of total billed charges,170.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,709.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,170.09,751.5,
RESOLUTION CLIP M00522612,1750066,CDM,272,RC,,,Outpatient,,,835,668,,709.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,170.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,471.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,471.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,471.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,471.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,751.5,90,,,percent of total billed charges,90% of total billed charges,292.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,573.65,68.7,,,percent of total billed charges,68.7% of total billed charges,668,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,484.3,58,,,percent of total billed charges,58% of total billed charges,170.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,709.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,170.09,751.5,
PARACENTESIS,2049080,CDM,450,RC,49080,HCPCS,Outpatient,,,835,668,,709.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,170.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,471.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,471.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,471.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,471.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,751.5,90,,,percent of total billed charges,90% of total billed charges,292.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,573.65,68.7,,,percent of total billed charges,68.7% of total billed charges,668,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,484.3,58,,,percent of total billed charges,58% of total billed charges,170.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,709.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,170.09,751.5,
.DENSITY GRADIENT SEPARATION,3086972,CDM,300,RC,86972,HCPCS,Outpatient,,,835,668,,709.75,85,,,percent of total billed charges,85% of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,179.8,130,,,fee schedule,Pays 130% Medicare OPPS,170.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,471.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,471.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,471.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,471.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,136.65,102,,,fee schedule,Pays 102% Medicare OPPS,751.5,90,,,percent of total billed charges,90% of total billed charges,292.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,573.65,68.7,,,percent of total billed charges,68.7% of total billed charges,668,80,,,percent of total billed charges,80 percent of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,120.57,90,,,fee schedule,Pays 90% Medicare OPPS,484.3,58,,,percent of total billed charges,58% of total billed charges,170.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,138.31,100,,,fee schedule,Pays 100% Medicare OPPS,179.8,130,,,fee schedule,Pays 130% Medicare OPPS,709.75,85,,,percent of total billed charges,85% of total billed charges,133.97,100,,,fee schedule,Pays 100% Medicare OPPS,120.57,751.5,
MESH 3D MAX R/L,7950129,CDM,278,RC,,,Both,,,835,668,,709.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,170.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,751.5,90,,,percent of total billed charges,90% of total billed charges,292.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,573.65,68.7,,,percent of total billed charges,68.7% of total billed charges,668,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,484.3,58,,,percent of total billed charges,58% of total billed charges,170.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,709.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,751.5,
LAC RPR CMPLX <2.5 CM,2013131,CDM,450,RC,,,Outpatient,,,840,672,,714,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,171.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,474.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,474.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,474.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,474.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,756,90,,,percent of total billed charges,90% of total billed charges,294,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,577.08,68.7,,,percent of total billed charges,68.7% of total billed charges,672,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,487.2,58,,,percent of total billed charges,58% of total billed charges,171.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,714,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,171.11,756,
.TISSUE CULT(CHROM 7 & 11),3088237,CDM,311,RC,88237,HCPCS,Outpatient,,,840,672,,714,85,,,percent of total billed charges,85% of total billed charges,143.75,100,,,fee schedule,Pays 100% Medicare OPPS,143.75,100,,,fee schedule,Pays 100% Medicare OPPS,143.75,100,,,fee schedule,Pays 100% Medicare OPPS,186.87,130,,,fee schedule,Pays 130% Medicare OPPS,133.63,120.37,,,fee schedule,120.37% of custom fee schedule,474.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,474.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,474.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,474.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.62,102,,,fee schedule,Pays 102% Medicare OPPS,756,90,,,percent of total billed charges,90% of total billed charges,138.97,125.18,,,fee schedule,125.18% of custom fee schedule,577.08,68.7,,,percent of total billed charges,68.7% of total billed charges,672,80,,,percent of total billed charges,80 percent of total billed charges,143.75,100,,,fee schedule,Pays 100% Medicare OPPS,129.37,90,,,fee schedule,Pays 90% Medicare OPPS,487.2,58,,,percent of total billed charges,58% of total billed charges,133.63,120.37,,,fee schedule,120.37% of custom fee schedule,143.75,100,,,fee schedule,Pays 100% Medicare OPPS,186.87,130,,,fee schedule,Pays 130% Medicare OPPS,714,85,,,percent of total billed charges,85% of total billed charges,143.75,100,,,fee schedule,Pays 100% Medicare OPPS,129.37,756,
XR FLUROSCOPY PORTACATH INSERT,4077001,CDM,320,RC,77001,HCPCS,Outpatient,,,840,672,,714,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,171.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,474.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,474.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,474.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,472.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,756,90,,,percent of total billed charges,90% of total billed charges,294,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,577.08,68.7,,,percent of total billed charges,68.7% of total billed charges,672,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,487.2,58,,,percent of total billed charges,58% of total billed charges,171.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,714,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,171.11,756,
Scan to measure bone mineral density (BMD) at the spine and hip,4176075,CDM,320,RC,77080,HCPCS,Outpatient,,,840,672,,714,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,171.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,474.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,474.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,474.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,472.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,756,90,,,percent of total billed charges,90% of total billed charges,294,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,577.08,68.7,,,percent of total billed charges,68.7% of total billed charges,672,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,487.2,58,,,percent of total billed charges,58% of total billed charges,171.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,714,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,756,
Ultrasound of fetus with limited views,4676815,CDM,402,RC,76815,HCPCS,Outpatient,,,840,672,,714,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,171.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,474.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,474.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,474.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,472.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,756,90,,,percent of total billed charges,90% of total billed charges,294,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,577.08,68.7,,,percent of total billed charges,68.7% of total billed charges,672,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,487.2,58,,,percent of total billed charges,58% of total billed charges,171.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,714,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,756,
Ultrasound of the scrotum,4676870,CDM,402,RC,76870,HCPCS,Outpatient,,,840,672,,714,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,171.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,474.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,474.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,474.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,472.08,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,756,90,,,percent of total billed charges,90% of total billed charges,294,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,577.08,68.7,,,percent of total billed charges,68.7% of total billed charges,672,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,487.2,58,,,percent of total billed charges,58% of total billed charges,171.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,714,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,756,
FOLEY CATH INSERTION SIMP,1051702,CDM,762,RC,51702,HCPCS,Outpatient,,,850,680,,722.5,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,173.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,480.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,480.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,480.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,480.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,765,90,,,percent of total billed charges,90% of total billed charges,297.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,583.95,68.7,,,percent of total billed charges,68.7% of total billed charges,680,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,493,58,,,percent of total billed charges,58% of total billed charges,173.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,722.5,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,765,
LENS INTRAOCULAR 34.0,1570173,CDM,276,RC,,,Outpatient,,,850,680,,722.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,173.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,765,90,,,percent of total billed charges,90% of total billed charges,297.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,583.95,68.7,,,percent of total billed charges,68.7% of total billed charges,680,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,493,58,,,percent of total billed charges,58% of total billed charges,173.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,722.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,765,
LENS INTRAOCULAR 33.0,1570174,CDM,276,RC,,,Outpatient,,,850,680,,722.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,173.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,765,90,,,percent of total billed charges,90% of total billed charges,297.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,583.95,68.7,,,percent of total billed charges,68.7% of total billed charges,680,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,493,58,,,percent of total billed charges,58% of total billed charges,173.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,722.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,765,
LENS INTRAOCULAR SN60AT 31.0,1570194,CDM,276,RC,,,Outpatient,,,850,680,,722.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,173.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,765,90,,,percent of total billed charges,90% of total billed charges,297.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,583.95,68.7,,,percent of total billed charges,68.7% of total billed charges,680,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,493,58,,,percent of total billed charges,58% of total billed charges,173.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,722.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,765,
LENS INTRAOCULAR SN60AT 32.0,1570199,CDM,276,RC,,,Outpatient,,,850,680,,722.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,173.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,765,90,,,percent of total billed charges,90% of total billed charges,297.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,583.95,68.7,,,percent of total billed charges,68.7% of total billed charges,680,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,493,58,,,percent of total billed charges,58% of total billed charges,173.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,722.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,765,
NOVAGOLD GUIDEWIRE .018 260CM,1750034,CDM,272,RC,,,Outpatient,,,850,680,,722.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,173.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,480.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,480.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,480.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,480.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,765,90,,,percent of total billed charges,90% of total billed charges,297.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,583.95,68.7,,,percent of total billed charges,68.7% of total billed charges,680,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,493,58,,,percent of total billed charges,58% of total billed charges,173.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,722.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,173.15,765,
"Emergency department visit, moderately severe problem",2099283,CDM,450,RC,99283,HCPCS,Outpatient,,,850,680,,722.5,85,,,percent of total billed charges,85% of total billed charges,207.88,100,,,fee schedule,Pays 100% Medicare OPPS,207.88,100,,,fee schedule,Pays 100% Medicare OPPS,207.88,100,,,fee schedule,Pays 100% Medicare OPPS,280.17,130,,,fee schedule,Pays 130% Medicare OPPS,173.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,850,100,,,percent of total billed charges,671 dollar flat fee for ER,850,100,,,percent of total billed charges,671 dollar flat fee for ER,850,100,,,percent of total billed charges,671 dollar flat fee for ER,850,100,,,percent of total billed charges,671 dollar flat fee for ER,212.04,102,,,fee schedule,Pays 102% Medicare OPPS,765,90,,,percent of total billed charges,90% of total billed charges,297.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,583.95,68.7,,,percent of total billed charges,68.7% of total billed charges,680,80,,,percent of total billed charges,80 percent of total billed charges,207.88,100,,,fee schedule,Pays 100% Medicare OPPS,187.09,90,,,fee schedule,Pays 90% Medicare OPPS,493,58,,,percent of total billed charges,58% of total billed charges,173.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,215.52,100,,,fee schedule,Pays 100% Medicare OPPS,280.17,130,,,fee schedule,Pays 130% Medicare OPPS,722.5,85,,,percent of total billed charges,85% of total billed charges,207.88,100,,,fee schedule,Pays 100% Medicare OPPS,173.15,850,
XR RIBS BILAT W/O CHEST 3 VIEWS,4071110,CDM,320,RC,71110,HCPCS,Outpatient,,,850,680,,722.5,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,173.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,480.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,480.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,480.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,477.7,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,765,90,,,percent of total billed charges,90% of total billed charges,297.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,583.95,68.7,,,percent of total billed charges,68.7% of total billed charges,680,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,493,58,,,percent of total billed charges,58% of total billed charges,173.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,722.5,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,765,
LENS INTRAOCULAR 7.0,1570088,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 6.0,1570090,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 8.5,1570091,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 9.5,1570093,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 10.0,1570094,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 10.5,1570095,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 11.0,1570096,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 11.5,1570097,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 12.0,1570098,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 12.5,1570099,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 13.0,1570101,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 13.5,1570102,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 14.0,1570103,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 14.5,1570104,CDM,270,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,175.18,774,
LENS INTRAOCULAR 15.0,1570105,CDM,270,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,175.18,774,
LENS INTRAOCULAR 15.5,1570106,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 16.0,1570107,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 16.5,1570108,CDM,270,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,175.18,774,
LENS INTRAOCULAR 17.0,1570109,CDM,270,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,175.18,774,
LENS INTRAOCULAR 17.5,1570110,CDM,270,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,175.18,774,
LENS INTRAOCULAR 18.0,1570111,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 18.5,1570112,CDM,270,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,175.18,774,
LENS INTRAOCULAR 19.0,1570113,CDM,270,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,175.18,774,
LENS INTRAOCULAR 19.5,1570114,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 20.0,1570115,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 20.5,1570116,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 21.0,1570120,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 21.5,1570125,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 22.0,1570126,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 22.5,1570130,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 23.0,1570131,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 23.5,1570135,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 24.0,1570140,CDM,270,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,175.18,774,
LENS INTRAOCULAR 24.5,1570141,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 25.0,1570150,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 25.5,1570151,CDM,270,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,175.18,774,
LENS INTRAOCULAR 26.0,1570155,CDM,270,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,175.18,774,
LENS INTRAOCULAR 26.5,1570156,CDM,270,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,175.18,774,
LENS INTRAOCULAR 27.0,1570160,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 27.5,1570165,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 28.0,1570166,CDM,270,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,175.18,774,
LENS INTRAOCULAR 28.5,1570167,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 29.0,1570168,CDM,270,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,175.18,774,
LENS INTRAOCULAR 29.5,1570169,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 30.0,1570170,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 570C18.0,1570267,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 570C18.5,1570268,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 570C19.0,1570269,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 570C19.5,1570270,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 570C20.5,1570271,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 570C21.0,1570272,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 570C21.5,1570273,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 570C22.5,1570274,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 570C23.0,1570275,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 570C23.5,1570276,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 570C29.5,1570277,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 570C24.0,1570278,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 570C25.5,1570279,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR 570C24.5,1570280,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR MI60L 5.0,1570300,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR MI60L 18.5,1570301,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR MI60L 20.5,1570302,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR MI60L 21.0,1570303,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR MI60L 21.5,1570304,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR MI60L 22.5,1570305,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR MI60L 24.5,1570306,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR MI60L 25.5,1570307,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR MN60MA 2.0,1570310,CDM,276,RC,V2797,HCPCS,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR MN60MA 5.0,1570311,CDM,276,RC,V2797,HCPCS,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR MN60AC 19.0,1570315,CDM,276,RC,V2797,HCPCS,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR MN60AC 21.0,1570319,CDM,276,RC,V2797,HCPCS,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR HOYA 11.50,1570321,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR HOYA 14.50,1570327,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR HOYA 16.00,1570330,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR HOYA 18.50,1570331,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR HOYA 20.00,1570332,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR HOYA 19.00,1570333,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR HOYA 21.00,1570334,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR HOYA 19.50,1570335,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR HOYA 22.00,1570336,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR HOYA 21.50,1570337,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR HOYA 22.50,1570338,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR HOYA 23.00,1570339,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR HOYA 23.50,1570340,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR HOYA 24.00,1570341,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR HOYA 24.50,1570342,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR HOYA 26.00,1570345,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
SCREW BONE 2.0 X 14MM SNAP-OFF,1570640,CDM,278,RC,C1713,HCPCS,Both,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS 7.5,1570655,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS 9.0,1570658,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS10.0,1570660,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS10.5,1570661,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS11.0,1570662,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS11.5,1570663,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS12.0,1570664,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS12.5,1570665,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS13.0,1570666,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS13.5,1570667,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS14.0,1570668,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS14.5,1570669,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS15.0,1570670,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS15.5,1570671,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS16.0,1570672,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS16.5,1570673,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS17.0,1570674,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS17.5,1570675,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS18.0,1570676,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS18.5,1570677,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS19.0,1570678,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS19.5,1570679,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS20.0,1570680,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS20.5,1570681,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS21.0,1570682,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS21.5,1570683,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS22.0,1570684,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS22.5,1570685,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS23.0,1570686,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS23.5,1570687,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS24.0,1570688,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS24.5,1570689,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS25.0,1570690,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS25.5,1570691,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS26.0,1570692,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS26.5,1570693,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS27.0,1570694,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS27.5,1570695,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS28.0,1570696,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS28.5,1570697,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS29.0,1570698,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS29.5,1570699,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR SN6CWS30.0,1570700,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOC HOYA 250 16.5,1570707,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOC HOYA 250 18.0,1570708,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOC HOYA 250 18.5,1570709,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOC HOYA 250 19.5,1570710,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOC HOYA 250 23.5,1570711,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOC HOYA 250 24.5,1570712,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 11.0,1570723,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 11.5,1570724,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 12.0,1570725,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 12.5,1570726,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 13.0,1570727,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 13.5,1570728,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 14.0,1570729,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 14.5,1570730,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 15.0,1570731,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 15.5,1570732,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 16.0,1570733,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 16.5,1570734,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 17.0,1570735,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 17.5,1570736,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 18.0,1570737,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 18.5,1570738,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 19.0,1570739,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 19.5,1570740,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 20.0,1570741,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 20.5,1570742,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 21.0,1570743,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 21.5,1570744,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 22.0,1570775,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 22.5,1570776,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 23.0,1570777,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 23.5,1570778,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 24.0,1570779,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 24.5,1570780,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 25.0,1570781,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 25.5,1570782,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 26.0,1570783,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 26.5,1570784,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
LENS INTRAOCULAR AU00T0 27.0,1570785,CDM,276,RC,,,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,774,
CAST LONG LEG QK C,2029345,CDM,450,RC,29345,HCPCS,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,274.32,130,,,fee schedule,Pays 130% Medicare OPPS,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,221.03,102,,,fee schedule,Pays 102% Medicare OPPS,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,195.03,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,211.02,100,,,fee schedule,Pays 100% Medicare OPPS,274.32,130,,,fee schedule,Pays 130% Medicare OPPS,731,85,,,percent of total billed charges,85% of total billed charges,216.71,100,,,fee schedule,Pays 100% Medicare OPPS,175.18,774,
REPAIR LACERATION <2.5 CM MOUTH,2041250,CDM,450,RC,41250,HCPCS,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,243.8,100,,,fee schedule,Pays 100% Medicare OPPS,243.8,100,,,fee schedule,Pays 100% Medicare OPPS,243.8,100,,,fee schedule,Pays 100% Medicare OPPS,431.73,130,,,fee schedule,Pays 130% Medicare OPPS,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,248.67,102,,,fee schedule,Pays 102% Medicare OPPS,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,243.8,100,,,fee schedule,Pays 100% Medicare OPPS,219.42,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,332.1,100,,,fee schedule,Pays 100% Medicare OPPS,431.73,130,,,fee schedule,Pays 130% Medicare OPPS,731,85,,,percent of total billed charges,85% of total billed charges,243.8,100,,,fee schedule,Pays 100% Medicare OPPS,175.18,774,
XR BARIUM SWALLOW,4074220,CDM,320,RC,74220,HCPCS,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.21,130,,,fee schedule,Pays 130% Medicare OPPS,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,483.32,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.67,102,,,fee schedule,Pays 102% Medicare OPPS,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.21,130,,,fee schedule,Pays 130% Medicare OPPS,731,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,774,
US AMNIOCENTESIS GUIDANC,4676946,CDM,402,RC,76946,HCPCS,Outpatient,,,860,688,,731,85,,,percent of total billed charges,85% of total billed charges,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,215,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,485.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,483.32,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,percent of total billed charges,90% of total billed charges,301,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,590.82,68.7,,,percent of total billed charges,68.7% of total billed charges,688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,774,90,,,fee schedule,Pays 90% Medicare OPPS,498.8,58,,,percent of total billed charges,58% of total billed charges,175.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,731,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,175.18,774,
ITMD WOUND REPAIR FACE 7.6-12.5CM,2012054,CDM,450,RC,12054,HCPCS,Outpatient,,,865,692,,735.25,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,176.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,316.7,102,,,fee schedule,Pays 102% Medicare OPPS,778.5,90,,,percent of total billed charges,90% of total billed charges,302.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,594.26,68.7,,,percent of total billed charges,68.7% of total billed charges,692,80,,,percent of total billed charges,80 percent of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,279.44,90,,,fee schedule,Pays 90% Medicare OPPS,501.7,58,,,percent of total billed charges,58% of total billed charges,176.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,328.14,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,735.25,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,176.2,778.5,
LAC RPR CMPLX 2.6-7.5 CM,2013121,CDM,450,RC,13121,HCPCS,Outpatient,,,865,692,,735.25,85,,,percent of total billed charges,85% of total billed charges,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,664.28,130,,,fee schedule,Pays 130% Medicare OPPS,176.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,479.88,102,,,fee schedule,Pays 102% Medicare OPPS,778.5,90,,,percent of total billed charges,90% of total billed charges,302.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,594.26,68.7,,,percent of total billed charges,68.7% of total billed charges,692,80,,,percent of total billed charges,80 percent of total billed charges,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,423.42,90,,,fee schedule,Pays 90% Medicare OPPS,501.7,58,,,percent of total billed charges,58% of total billed charges,176.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,510.99,100,,,fee schedule,Pays 100% Medicare OPPS,664.28,130,,,fee schedule,Pays 130% Medicare OPPS,735.25,85,,,percent of total billed charges,85% of total billed charges,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,176.2,778.5,
LAC RPR CMPLX 2.6-7.5 CM,2013132,CDM,450,RC,,,Outpatient,,,865,692,,735.25,85,,,percent of total billed charges,85% of total billed charges,216.25,100,,,fee schedule,Pays 100% Medicare OPPS,216.25,100,,,fee schedule,Pays 100% Medicare OPPS,216.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,176.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,778.5,90,,,percent of total billed charges,90% of total billed charges,302.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,594.26,68.7,,,percent of total billed charges,68.7% of total billed charges,692,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,778.5,90,,,fee schedule,Pays 90% Medicare OPPS,501.7,58,,,percent of total billed charges,58% of total billed charges,176.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,735.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,176.2,778.5,
SOMATOSTATIN,3084307,CDM,301,RC,84307,HCPCS,Outpatient,,,865,692,,735.25,85,,,percent of total billed charges,85% of total billed charges,18.28,100,,,fee schedule,Pays 100% Medicare OPPS,18.28,100,,,fee schedule,Pays 100% Medicare OPPS,18.28,100,,,fee schedule,Pays 100% Medicare OPPS,23.76,130,APC,,fee schedule,Pays 130% Medicare OPPS,27.67,120.37,,,fee schedule,120.37% of custom fee schedule,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.64,102,,,fee schedule,Pays 102% Medicare OPPS,778.5,90,,,percent of total billed charges,90% of total billed charges,28.78,125.18,,,fee schedule,125.18% of custom fee schedule,594.26,68.7,,,percent of total billed charges,68.7% of total billed charges,692,80,,,percent of total billed charges,80 percent of total billed charges,18.28,100,,,fee schedule,Pays 100% Medicare OPPS,16.45,90,,,fee schedule,Pays 90% Medicare OPPS,501.7,58,,,percent of total billed charges,58% of total billed charges,27.67,120.37,,,fee schedule,120.37% of custom fee schedule,18.28,100,,,fee schedule,Pays 100% Medicare OPPS,23.76,130,APC,,fee schedule,Pays 130% Medicare OPPS,735.25,85,,,percent of total billed charges,85% of total billed charges,18.28,100,,,fee schedule,Pays 100% Medicare OPPS,16.45,778.5,
NM PULMONARY VENTILATION/PERFUSION,4578582,CDM,341,RC,78582,HCPCS,Outpatient,,,865,692,,735.25,85,,,percent of total billed charges,85% of total billed charges,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,576.87,130,,,fee schedule,Pays 130% Medicare OPPS,176.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,448.38,102,,,fee schedule,Pays 102% Medicare OPPS,778.5,90,,,percent of total billed charges,90% of total billed charges,302.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,594.26,68.7,,,percent of total billed charges,68.7% of total billed charges,692,80,,,percent of total billed charges,80 percent of total billed charges,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,395.63,90,,,fee schedule,Pays 90% Medicare OPPS,501.7,58,,,percent of total billed charges,58% of total billed charges,176.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,443.74,100,,,fee schedule,Pays 100% Medicare OPPS,576.87,130,,,fee schedule,Pays 130% Medicare OPPS,735.25,85,,,percent of total billed charges,85% of total billed charges,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,176.2,778.5,
NM PULMONARY VENTILATION SCAN,4578587,CDM,341,RC,78579,HCPCS,Outpatient,,,865,692,,735.25,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,176.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,345.39,102,,,fee schedule,Pays 102% Medicare OPPS,778.5,90,,,percent of total billed charges,90% of total billed charges,302.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,594.26,68.7,,,percent of total billed charges,68.7% of total billed charges,692,80,,,percent of total billed charges,80 percent of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,304.76,90,,,fee schedule,Pays 90% Medicare OPPS,501.7,58,,,percent of total billed charges,58% of total billed charges,176.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,341.87,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,735.25,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,176.2,778.5,
US DUPLEX ART ABD LTD,4600022,CDM,921,RC,93976,HCPCS,Outpatient,,,865,692,,735.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,176.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,488.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,778.5,90,,,percent of total billed charges,90% of total billed charges,302.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,594.26,68.7,,,percent of total billed charges,68.7% of total billed charges,692,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,501.7,58,,,percent of total billed charges,58% of total billed charges,176.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,735.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,778.5,
REPAIR POSTOPERATIVE HEMORRHAGE/EXT,2035860,CDM,450,RC,,,Outpatient,,,875,700,,743.75,85,,,percent of total billed charges,85% of total billed charges,218.75,100,,,fee schedule,Pays 100% Medicare OPPS,218.75,100,,,fee schedule,Pays 100% Medicare OPPS,218.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,178.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,494.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,494.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,494.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,494.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,787.5,90,,,percent of total billed charges,90% of total billed charges,306.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,601.13,68.7,,,percent of total billed charges,68.7% of total billed charges,700,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,787.5,90,,,fee schedule,Pays 90% Medicare OPPS,507.5,58,,,percent of total billed charges,58% of total billed charges,178.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,743.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,178.24,787.5,
ALPHA MELANOCYTE STIMULATING HORMONE,3000555,CDM,300,RC,83520,HCPCS,Outpatient,,,875,700,,743.75,85,,,percent of total billed charges,85% of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,130,,,fee schedule,Pays 130% Medicare OPPS,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,494.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,494.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,494.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,494.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.61,102,,,fee schedule,Pays 102% Medicare OPPS,787.5,90,,,percent of total billed charges,90% of total billed charges,20.38,125.18,,,fee schedule,125.18% of custom fee schedule,601.13,68.7,,,percent of total billed charges,68.7% of total billed charges,700,80,,,percent of total billed charges,80 percent of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,15.54,90,,,fee schedule,Pays 90% Medicare OPPS,507.5,58,,,percent of total billed charges,58% of total billed charges,19.6,120.37,,,fee schedule,120.37% of custom fee schedule,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,22.45,130,,,fee schedule,Pays 130% Medicare OPPS,743.75,85,,,percent of total billed charges,85% of total billed charges,17.27,100,,,fee schedule,Pays 100% Medicare OPPS,15.54,787.5,
US CYST GUIDANCE NEEDLE,4676942,CDM,402,RC,76942,HCPCS,Outpatient,,,875,700,,743.75,85,,,percent of total billed charges,85% of total billed charges,218.75,100,,,fee schedule,Pays 100% Medicare OPPS,218.75,100,,,fee schedule,Pays 100% Medicare OPPS,218.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,178.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,494.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,494.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,494.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,491.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,787.5,90,,,percent of total billed charges,90% of total billed charges,306.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,601.13,68.7,,,percent of total billed charges,68.7% of total billed charges,700,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,787.5,90,,,fee schedule,Pays 90% Medicare OPPS,507.5,58,,,percent of total billed charges,58% of total billed charges,178.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,743.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,178.24,787.5,
US GUIDANCE INTRAOPERATIVE,4676998,CDM,402,RC,76998,HCPCS,Outpatient,,,875,700,,743.75,85,,,percent of total billed charges,85% of total billed charges,218.75,100,,,fee schedule,Pays 100% Medicare OPPS,218.75,100,,,fee schedule,Pays 100% Medicare OPPS,218.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,178.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,494.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,494.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,494.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,491.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,787.5,90,,,percent of total billed charges,90% of total billed charges,306.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,601.13,68.7,,,percent of total billed charges,68.7% of total billed charges,700,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,787.5,90,,,fee schedule,Pays 90% Medicare OPPS,507.5,58,,,percent of total billed charges,58% of total billed charges,178.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,743.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,178.24,787.5,
US ARTERIAL-SCROTAL-LIMITED,4693976,CDM,921,RC,93976,HCPCS,Outpatient,,,875,700,,743.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,178.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,494.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,494.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,494.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,494.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,787.5,90,,,percent of total billed charges,90% of total billed charges,306.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,601.13,68.7,,,percent of total billed charges,68.7% of total billed charges,700,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,507.5,58,,,percent of total billed charges,58% of total billed charges,178.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,743.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,787.5,
TROCAR 12 MM 512B,7950169,CDM,270,RC,,,Outpatient,,,875,700,,743.75,85,,,percent of total billed charges,85% of total billed charges,218.75,100,,,fee schedule,Pays 100% Medicare OPPS,218.75,100,,,fee schedule,Pays 100% Medicare OPPS,218.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,178.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,494.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,494.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,494.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,494.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,787.5,90,,,percent of total billed charges,90% of total billed charges,306.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,601.13,68.7,,,percent of total billed charges,68.7% of total billed charges,700,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,787.5,90,,,fee schedule,Pays 90% Medicare OPPS,507.5,58,,,percent of total billed charges,58% of total billed charges,178.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,743.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,178.24,787.5,
CHEST TUBE INSERTION,2032000,CDM,450,RC,,,Outpatient,,,885,708,,752.25,85,,,percent of total billed charges,85% of total billed charges,221.25,100,,,fee schedule,Pays 100% Medicare OPPS,221.25,100,,,fee schedule,Pays 100% Medicare OPPS,221.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,180.27,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,796.5,90,,,percent of total billed charges,90% of total billed charges,309.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,608,68.7,,,percent of total billed charges,68.7% of total billed charges,708,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,796.5,90,,,fee schedule,Pays 90% Medicare OPPS,513.3,58,,,percent of total billed charges,58% of total billed charges,180.27,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,752.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,180.27,796.5,
PANCREASTIN LEVEL,3000225,CDM,301,RC,83519,HCPCS,Outpatient,,,885,708,,752.25,85,,,percent of total billed charges,85% of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,23.92,130,,,fee schedule,Pays 130% Medicare OPPS,20.45,120.37,,,fee schedule,120.37% of custom fee schedule,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,18.76,102,,,fee schedule,Pays 102% Medicare OPPS,796.5,90,,,percent of total billed charges,90% of total billed charges,21.27,125.18,,,fee schedule,125.18% of custom fee schedule,608,68.7,,,percent of total billed charges,68.7% of total billed charges,708,80,,,percent of total billed charges,80 percent of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.55,90,,,fee schedule,Pays 90% Medicare OPPS,513.3,58,,,percent of total billed charges,58% of total billed charges,20.45,120.37,,,fee schedule,120.37% of custom fee schedule,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,23.92,130,,,fee schedule,Pays 130% Medicare OPPS,752.25,85,,,percent of total billed charges,85% of total billed charges,18.39,100,,,fee schedule,Pays 100% Medicare OPPS,16.55,796.5,
3RD PANCREATIC ELASTASE,3000691,CDM,301,RC,82656,HCPCS,Outpatient,,,885,708,,752.25,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,APC,,fee schedule,Pays 130% Medicare OPPS,180.27,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,11.76,102,,,fee schedule,Pays 102% Medicare OPPS,796.5,90,,,percent of total billed charges,90% of total billed charges,309.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,608,68.7,,,percent of total billed charges,68.7% of total billed charges,708,80,,,percent of total billed charges,80 percent of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,90,,,fee schedule,Pays 90% Medicare OPPS,513.3,58,,,percent of total billed charges,58% of total billed charges,180.27,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,14.98,130,APC,,fee schedule,Pays 130% Medicare OPPS,752.25,85,,,percent of total billed charges,85% of total billed charges,11.53,100,,,fee schedule,Pays 100% Medicare OPPS,10.37,796.5,
XR BARIUM SWALLOW/MODIFIED,4074230,CDM,320,RC,74230,HCPCS,Outpatient,,,885,708,,752.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.21,130,,,fee schedule,Pays 130% Medicare OPPS,180.27,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,497.37,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.67,102,,,fee schedule,Pays 102% Medicare OPPS,796.5,90,,,percent of total billed charges,90% of total billed charges,309.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,608,68.7,,,percent of total billed charges,68.7% of total billed charges,708,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,513.3,58,,,percent of total billed charges,58% of total billed charges,180.27,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.21,130,,,fee schedule,Pays 130% Medicare OPPS,752.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,796.5,
One sided or limited bilateral study,4600020,CDM,921,RC,93971,HCPCS,Outpatient,,,885,708,,752.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,180.27,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,796.5,90,,,percent of total billed charges,90% of total billed charges,309.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,608,68.7,,,percent of total billed charges,68.7% of total billed charges,708,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,513.3,58,,,percent of total billed charges,58% of total billed charges,180.27,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,752.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,796.5,
One sided or limited bilateral study,4600021,CDM,921,RC,93971,HCPCS,Outpatient,,,885,708,,752.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,180.27,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,796.5,90,,,percent of total billed charges,90% of total billed charges,309.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,608,68.7,,,percent of total billed charges,68.7% of total billed charges,708,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,513.3,58,,,percent of total billed charges,58% of total billed charges,180.27,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,752.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,796.5,
One sided or limited bilateral study,4600939,CDM,921,RC,93971,HCPCS,Outpatient,,,885,708,,752.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,180.27,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,796.5,90,,,percent of total billed charges,90% of total billed charges,309.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,608,68.7,,,percent of total billed charges,68.7% of total billed charges,708,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,513.3,58,,,percent of total billed charges,58% of total billed charges,180.27,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,752.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,796.5,
One sided or limited bilateral study,4600971,CDM,921,RC,93971,HCPCS,Outpatient,,,885,708,,752.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,180.27,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,500.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,796.5,90,,,percent of total billed charges,90% of total billed charges,309.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,608,68.7,,,percent of total billed charges,68.7% of total billed charges,708,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,513.3,58,,,percent of total billed charges,58% of total billed charges,180.27,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,752.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,796.5,
SIZER IMPLANT BREAST RSZ-SHPX-260S,1570965,CDM,278,RC,,,Both,,,896,716.8,,761.6,85,,,percent of total billed charges,85% of total billed charges,224,100,,,fee schedule,Pays 100% Medicare OPPS,224,100,,,fee schedule,Pays 100% Medicare OPPS,224,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,182.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,806.4,90,,,percent of total billed charges,90% of total billed charges,313.6,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,615.55,68.7,,,percent of total billed charges,68.7% of total billed charges,716.8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,806.4,90,,,fee schedule,Pays 90% Medicare OPPS,519.68,58,,,percent of total billed charges,58% of total billed charges,182.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,761.6,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,806.4,
SIZER IMPLANT BREAST RSZ-SHPX-335S,1570966,CDM,278,RC,,,Both,,,896,716.8,,761.6,85,,,percent of total billed charges,85% of total billed charges,224,100,,,fee schedule,Pays 100% Medicare OPPS,224,100,,,fee schedule,Pays 100% Medicare OPPS,224,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,182.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,806.4,90,,,percent of total billed charges,90% of total billed charges,313.6,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,615.55,68.7,,,percent of total billed charges,68.7% of total billed charges,716.8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,806.4,90,,,fee schedule,Pays 90% Medicare OPPS,519.68,58,,,percent of total billed charges,58% of total billed charges,182.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,761.6,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,806.4,
BLADE KOBYGARD 380-0006,1570772,CDM,272,RC,,,Outpatient,,,900,720,,765,85,,,percent of total billed charges,85% of total billed charges,225,100,,,fee schedule,Pays 100% Medicare OPPS,225,100,,,fee schedule,Pays 100% Medicare OPPS,225,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,183.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,508.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,508.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,508.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,508.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,810,90,,,percent of total billed charges,90% of total billed charges,315,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,618.3,68.7,,,percent of total billed charges,68.7% of total billed charges,720,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,810,90,,,fee schedule,Pays 90% Medicare OPPS,522,58,,,percent of total billed charges,58% of total billed charges,183.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,765,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,183.33,810,
SPERM ANTIBODIES,3000287,CDM,302,RC,86255,HCPCS,Outpatient,,,900,720,,765,85,,,percent of total billed charges,85% of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,APC,,fee schedule,Pays 130% Medicare OPPS,18.25,120.37,,,fee schedule,120.37% of custom fee schedule,508.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,508.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,508.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,508.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,12.29,102,,,fee schedule,Pays 102% Medicare OPPS,810,90,,,percent of total billed charges,90% of total billed charges,18.98,125.18,,,fee schedule,125.18% of custom fee schedule,618.3,68.7,,,percent of total billed charges,68.7% of total billed charges,720,80,,,percent of total billed charges,80 percent of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,10.84,90,,,fee schedule,Pays 90% Medicare OPPS,522,58,,,percent of total billed charges,58% of total billed charges,18.25,120.37,,,fee schedule,120.37% of custom fee schedule,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,15.66,130,APC,,fee schedule,Pays 130% Medicare OPPS,765,85,,,percent of total billed charges,85% of total billed charges,12.05,100,,,fee schedule,Pays 100% Medicare OPPS,10.84,810,
3RD FLOW CYTOMETRY,3088182,CDM,311,RC,88182,HCPCS,Outpatient,,,900,720,,765,85,,,percent of total billed charges,85% of total billed charges,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,57.33,130,,,fee schedule,Pays 130% Medicare OPPS,80.6,120.37,,,fee schedule,120.37% of custom fee schedule,508.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,508.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,508.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,508.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,45.53,102,,,fee schedule,Pays 102% Medicare OPPS,810,90,,,percent of total billed charges,90% of total billed charges,83.82,125.18,,,fee schedule,125.18% of custom fee schedule,618.3,68.7,,,percent of total billed charges,68.7% of total billed charges,720,80,,,percent of total billed charges,80 percent of total billed charges,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,40.17,90,,,fee schedule,Pays 90% Medicare OPPS,522,58,,,percent of total billed charges,58% of total billed charges,80.6,120.37,,,fee schedule,120.37% of custom fee schedule,44.1,100,,,fee schedule,Pays 100% Medicare OPPS,57.33,130,,,fee schedule,Pays 130% Medicare OPPS,765,85,,,percent of total billed charges,85% of total billed charges,44.63,100,,,fee schedule,Pays 100% Medicare OPPS,40.17,810,
Ultrasound of head and neck,4676536,CDM,402,RC,76536,HCPCS,Outpatient,,,900,720,,765,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,183.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,508.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,508.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,508.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,505.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,810,90,,,percent of total billed charges,90% of total billed charges,315,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,618.3,68.7,,,percent of total billed charges,68.7% of total billed charges,720,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,522,58,,,percent of total billed charges,58% of total billed charges,183.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,765,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,810,
APOLLO RF 90DEG MULTIPORT ABLATOR,1570824,CDM,272,RC,,,Outpatient,,,905,724,,769.25,85,,,percent of total billed charges,85% of total billed charges,226.25,100,,,fee schedule,Pays 100% Medicare OPPS,226.25,100,,,fee schedule,Pays 100% Medicare OPPS,226.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,184.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,511.33,56.5,,,percent of total billed charges,56.5 percent of total billed charges,511.33,56.5,,,percent of total billed charges,56.5 percent of total billed charges,511.33,56.5,,,percent of total billed charges,56.5 percent of total billed charges,511.33,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,814.5,90,,,percent of total billed charges,90% of total billed charges,316.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,621.74,68.7,,,percent of total billed charges,68.7% of total billed charges,724,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,814.5,90,,,fee schedule,Pays 90% Medicare OPPS,524.9,58,,,percent of total billed charges,58% of total billed charges,184.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,769.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,184.35,814.5,
OPTICAL DILATOR IN0216,1750005,CDM,270,RC,,,Outpatient,,,910,728,,773.5,85,,,percent of total billed charges,85% of total billed charges,227.5,100,,,fee schedule,Pays 100% Medicare OPPS,227.5,100,,,fee schedule,Pays 100% Medicare OPPS,227.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,185.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,819,90,,,percent of total billed charges,90% of total billed charges,318.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,625.17,68.7,,,percent of total billed charges,68.7% of total billed charges,728,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,819,90,,,fee schedule,Pays 90% Medicare OPPS,527.8,58,,,percent of total billed charges,58% of total billed charges,185.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,773.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,185.37,819,
OPTICAL DILATOR IN0218,1750006,CDM,270,RC,,,Outpatient,,,910,728,,773.5,85,,,percent of total billed charges,85% of total billed charges,227.5,100,,,fee schedule,Pays 100% Medicare OPPS,227.5,100,,,fee schedule,Pays 100% Medicare OPPS,227.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,185.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,819,90,,,percent of total billed charges,90% of total billed charges,318.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,625.17,68.7,,,percent of total billed charges,68.7% of total billed charges,728,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,819,90,,,fee schedule,Pays 90% Medicare OPPS,527.8,58,,,percent of total billed charges,58% of total billed charges,185.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,773.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,185.37,819,
OPTICAL DILATOR IN0220,1750007,CDM,270,RC,,,Outpatient,,,910,728,,773.5,85,,,percent of total billed charges,85% of total billed charges,227.5,100,,,fee schedule,Pays 100% Medicare OPPS,227.5,100,,,fee schedule,Pays 100% Medicare OPPS,227.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,185.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,819,90,,,percent of total billed charges,90% of total billed charges,318.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,625.17,68.7,,,percent of total billed charges,68.7% of total billed charges,728,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,819,90,,,fee schedule,Pays 90% Medicare OPPS,527.8,58,,,percent of total billed charges,58% of total billed charges,185.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,773.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,185.37,819,
THORACENTESIS DRAIN CHEST,2032001,CDM,450,RC,32421,HCPCS,Outpatient,,,910,728,,773.5,85,,,percent of total billed charges,85% of total billed charges,227.5,100,,,fee schedule,Pays 100% Medicare OPPS,227.5,100,,,fee schedule,Pays 100% Medicare OPPS,227.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,185.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,819,90,,,percent of total billed charges,90% of total billed charges,318.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,625.17,68.7,,,percent of total billed charges,68.7% of total billed charges,728,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,819,90,,,fee schedule,Pays 90% Medicare OPPS,527.8,58,,,percent of total billed charges,58% of total billed charges,185.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,773.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,185.37,819,
THORACENTESIS INSERT TUBE,2032002,CDM,450,RC,32421,HCPCS,Outpatient,,,910,728,,773.5,85,,,percent of total billed charges,85% of total billed charges,227.5,100,,,fee schedule,Pays 100% Medicare OPPS,227.5,100,,,fee schedule,Pays 100% Medicare OPPS,227.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,185.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,819,90,,,percent of total billed charges,90% of total billed charges,318.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,625.17,68.7,,,percent of total billed charges,68.7% of total billed charges,728,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,819,90,,,fee schedule,Pays 90% Medicare OPPS,527.8,58,,,percent of total billed charges,58% of total billed charges,185.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,773.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,185.37,819,
3RD HEPATITIS C GENOTYPE,3000146,CDM,300,RC,87902,HCPCS,Outpatient,,,910,728,,773.5,85,,,percent of total billed charges,85% of total billed charges,257.45,100,,,fee schedule,Pays 100% Medicare OPPS,257.45,100,,,fee schedule,Pays 100% Medicare OPPS,257.45,100,,,fee schedule,Pays 100% Medicare OPPS,334.68,130,,,fee schedule,Pays 130% Medicare OPPS,132.01,120.37,,,fee schedule,120.37% of custom fee schedule,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.59,102,,,fee schedule,Pays 102% Medicare OPPS,819,90,,,percent of total billed charges,90% of total billed charges,137.28,125.18,,,fee schedule,125.18% of custom fee schedule,625.17,68.7,,,percent of total billed charges,68.7% of total billed charges,728,80,,,percent of total billed charges,80 percent of total billed charges,257.45,100,,,fee schedule,Pays 100% Medicare OPPS,231.7,90,,,fee schedule,Pays 90% Medicare OPPS,527.8,58,,,percent of total billed charges,58% of total billed charges,132.01,120.37,,,fee schedule,120.37% of custom fee schedule,257.45,100,,,fee schedule,Pays 100% Medicare OPPS,334.68,130,,,fee schedule,Pays 130% Medicare OPPS,773.5,85,,,percent of total billed charges,85% of total billed charges,257.45,100,,,fee schedule,Pays 100% Medicare OPPS,132.01,819,
3RD CORTISOL FREE SERUM,3082531,CDM,301,RC,82530,HCPCS,Outpatient,,,910,728,,773.5,85,,,percent of total billed charges,85% of total billed charges,16.71,100,,,fee schedule,Pays 100% Medicare OPPS,16.71,100,,,fee schedule,Pays 100% Medicare OPPS,16.71,100,,,fee schedule,Pays 100% Medicare OPPS,21.72,130,APC,,fee schedule,Pays 130% Medicare OPPS,25.3,120.37,,,fee schedule,120.37% of custom fee schedule,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,514.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.04,102,,,fee schedule,Pays 102% Medicare OPPS,819,90,,,percent of total billed charges,90% of total billed charges,26.31,125.18,,,fee schedule,125.18% of custom fee schedule,625.17,68.7,,,percent of total billed charges,68.7% of total billed charges,728,80,,,percent of total billed charges,80 percent of total billed charges,16.71,100,,,fee schedule,Pays 100% Medicare OPPS,15.03,90,,,fee schedule,Pays 90% Medicare OPPS,527.8,58,,,percent of total billed charges,58% of total billed charges,25.3,120.37,,,fee schedule,120.37% of custom fee schedule,16.71,100,,,fee schedule,Pays 100% Medicare OPPS,21.72,130,APC,,fee schedule,Pays 130% Medicare OPPS,773.5,85,,,percent of total billed charges,85% of total billed charges,16.71,100,,,fee schedule,Pays 100% Medicare OPPS,15.03,819,
N BLOCK INJ PLANTAR DIGIT,2064455,CDM,450,RC,64455,HCPCS,Outpatient,,,915,732,,777.75,85,,,percent of total billed charges,85% of total billed charges,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,310.88,130,,,fee schedule,Pays 130% Medicare OPPS,186.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,516.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,516.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,516.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,516.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,239.38,102,,,fee schedule,Pays 102% Medicare OPPS,823.5,90,,,percent of total billed charges,90% of total billed charges,320.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,628.61,68.7,,,percent of total billed charges,68.7% of total billed charges,732,80,,,percent of total billed charges,80 percent of total billed charges,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,211.22,90,,,fee schedule,Pays 90% Medicare OPPS,530.7,58,,,percent of total billed charges,58% of total billed charges,186.39,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,239.14,100,,,fee schedule,Pays 100% Medicare OPPS,310.88,130,,,fee schedule,Pays 130% Medicare OPPS,777.75,85,,,percent of total billed charges,85% of total billed charges,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,186.39,823.5,
"Incision and drainage of hematoma, seroma or fluid collection",2000002,CDM,450,RC,10140,HCPCS,Outpatient,,,920,736,,782,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,187.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,519.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,519.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,519.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,519.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1289.21,102,,,fee schedule,Pays 102% Medicare OPPS,828,90,,,percent of total billed charges,90% of total billed charges,322,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,632.04,68.7,,,percent of total billed charges,68.7% of total billed charges,736,80,,,percent of total billed charges,80 percent of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1137.55,90,,,fee schedule,Pays 90% Medicare OPPS,533.6,58,,,percent of total billed charges,58% of total billed charges,187.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1318.97,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,782,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,187.4,1714.66,
AMBULANCE ALS,2000427,CDM,540,RC,A0427,HCPCS,Outpatient,,,920,736,,782,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,187.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,519.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,519.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,519.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,519.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,828,90,,,percent of total billed charges,90% of total billed charges,322,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,632.04,68.7,,,percent of total billed charges,68.7% of total billed charges,736,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,533.6,58,,,percent of total billed charges,58% of total billed charges,187.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,782,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,187.4,828,
DEBRID SKIN PRTL SUBCUTAN,2011042,CDM,450,RC,11042,HCPCS,Outpatient,,,920,736,,782,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,187.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,519.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,519.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,519.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,519.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,316.7,102,,,fee schedule,Pays 102% Medicare OPPS,828,90,,,percent of total billed charges,90% of total billed charges,322,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,632.04,68.7,,,percent of total billed charges,68.7% of total billed charges,736,80,,,percent of total billed charges,80 percent of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,279.44,90,,,fee schedule,Pays 90% Medicare OPPS,533.6,58,,,percent of total billed charges,58% of total billed charges,187.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,328.14,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,782,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,187.4,828,
LAC SIMPLE >30 CM,2012007,CDM,450,RC,12007,HCPCS,Outpatient,,,920,736,,782,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,187.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,519.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,519.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,519.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,519.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,164.53,102,,,fee schedule,Pays 102% Medicare OPPS,828,90,,,percent of total billed charges,90% of total billed charges,322,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,632.04,68.7,,,percent of total billed charges,68.7% of total billed charges,736,80,,,percent of total billed charges,80 percent of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,145.18,90,,,fee schedule,Pays 90% Medicare OPPS,533.6,58,,,percent of total billed charges,58% of total billed charges,187.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.83,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,782,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,145.18,828,
INJ ANES LUMBAR/THORACIC,2064520,CDM,450,RC,64520,HCPCS,Outpatient,,,925,740,,786.25,85,,,percent of total billed charges,85% of total billed charges,739.49,100,,,fee schedule,Pays 100% Medicare OPPS,739.49,100,,,fee schedule,Pays 100% Medicare OPPS,739.49,100,,,fee schedule,Pays 100% Medicare OPPS,974.42,130,,,fee schedule,Pays 130% Medicare OPPS,188.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,522.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,522.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,522.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,522.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,754.27,102,,,fee schedule,Pays 102% Medicare OPPS,832.5,90,,,percent of total billed charges,90% of total billed charges,323.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,635.48,68.7,,,percent of total billed charges,68.7% of total billed charges,740,80,,,percent of total billed charges,80 percent of total billed charges,739.49,100,,,fee schedule,Pays 100% Medicare OPPS,665.53,90,,,fee schedule,Pays 90% Medicare OPPS,536.5,58,,,percent of total billed charges,58% of total billed charges,188.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,749.56,100,,,fee schedule,Pays 100% Medicare OPPS,974.42,130,,,fee schedule,Pays 130% Medicare OPPS,786.25,85,,,percent of total billed charges,85% of total billed charges,739.49,100,,,fee schedule,Pays 100% Medicare OPPS,188.42,974.42,
LIGATOR SPEEDBAND SUPERVIEW SUPER 7,1750018,CDM,270,RC,,,Outpatient,,,935,748,,794.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,190.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,528.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,528.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,528.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,528.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,841.5,90,,,percent of total billed charges,90% of total billed charges,327.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,642.35,68.7,,,percent of total billed charges,68.7% of total billed charges,748,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,542.3,58,,,percent of total billed charges,58% of total billed charges,190.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,794.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,190.46,841.5,
CHEST TUBE TRY THAL QUICK,7950198,CDM,270,RC,,,Outpatient,,,935,748,,794.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,190.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,528.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,528.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,528.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,528.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,841.5,90,,,percent of total billed charges,90% of total billed charges,327.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,642.35,68.7,,,percent of total billed charges,68.7% of total billed charges,748,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,542.3,58,,,percent of total billed charges,58% of total billed charges,190.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,794.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,190.46,841.5,
CHEST TUBE TRY THAL QUICK,7950199,CDM,270,RC,,,Outpatient,,,935,748,,794.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,190.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,528.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,528.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,528.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,528.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,841.5,90,,,percent of total billed charges,90% of total billed charges,327.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,642.35,68.7,,,percent of total billed charges,68.7% of total billed charges,748,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,542.3,58,,,percent of total billed charges,58% of total billed charges,190.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,794.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,190.46,841.5,
3RD HEP C VIRAL LOAD,3000546,CDM,306,RC,87522,HCPCS,Outpatient,,,940,752,,799,85,,,percent of total billed charges,85% of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,130,,,fee schedule,Pays 130% Medicare OPPS,64.84,120.37,,,fee schedule,120.37% of custom fee schedule,531.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,531.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,531.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,531.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,43.69,102,,,fee schedule,Pays 102% Medicare OPPS,846,90,,,percent of total billed charges,90% of total billed charges,67.43,125.18,,,fee schedule,125.18% of custom fee schedule,645.78,68.7,,,percent of total billed charges,68.7% of total billed charges,752,80,,,percent of total billed charges,80 percent of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,38.55,90,,,fee schedule,Pays 90% Medicare OPPS,545.2,58,,,percent of total billed charges,58% of total billed charges,64.84,120.37,,,fee schedule,120.37% of custom fee schedule,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,130,,,fee schedule,Pays 130% Medicare OPPS,799,85,,,percent of total billed charges,85% of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,38.55,846,
3RD HEP C RNA QUANTITATIVE,3087522,CDM,306,RC,87522,HCPCS,Outpatient,,,940,752,,799,85,,,percent of total billed charges,85% of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,130,APC,,fee schedule,Pays 130% Medicare OPPS,64.84,120.37,,,fee schedule,120.37% of custom fee schedule,531.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,531.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,531.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,531.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,43.69,102,,,fee schedule,Pays 102% Medicare OPPS,846,90,,,percent of total billed charges,90% of total billed charges,67.43,125.18,,,fee schedule,125.18% of custom fee schedule,645.78,68.7,,,percent of total billed charges,68.7% of total billed charges,752,80,,,percent of total billed charges,80 percent of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,38.55,90,,,fee schedule,Pays 90% Medicare OPPS,545.2,58,,,percent of total billed charges,58% of total billed charges,64.84,120.37,,,fee schedule,120.37% of custom fee schedule,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,130,APC,,fee schedule,Pays 130% Medicare OPPS,799,85,,,percent of total billed charges,85% of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,38.55,846,
XR IVP,4074410,CDM,320,RC,74410,HCPCS,Outpatient,,,940,752,,799,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,191.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,531.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,531.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,531.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,528.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,846,90,,,percent of total billed charges,90% of total billed charges,329,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,645.78,68.7,,,percent of total billed charges,68.7% of total billed charges,752,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,545.2,58,,,percent of total billed charges,58% of total billed charges,191.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,799,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,846,
US AV GRAFT IMAGE,4693990,CDM,921,RC,93990,HCPCS,Outpatient,,,940,752,,799,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,191.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,531.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,531.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,531.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,531.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,846,90,,,percent of total billed charges,90% of total billed charges,329,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,645.78,68.7,,,percent of total billed charges,68.7% of total billed charges,752,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,545.2,58,,,percent of total billed charges,58% of total billed charges,191.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,799,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,846,
BIOPSY PROBE MAMMOTOME ELITE,7950308,CDM,272,RC,,,Outpatient,,,941,752.8,,799.85,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,191.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,531.67,56.5,,,percent of total billed charges,56.5 percent of total billed charges,531.67,56.5,,,percent of total billed charges,56.5 percent of total billed charges,531.67,56.5,,,percent of total billed charges,56.5 percent of total billed charges,531.67,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,846.9,90,,,percent of total billed charges,90% of total billed charges,329.35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,646.47,68.7,,,percent of total billed charges,68.7% of total billed charges,752.8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,545.78,58,,,percent of total billed charges,58% of total billed charges,191.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,799.85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,191.68,846.9,
APOLLO RF 50DEG MULTIPORT ABLATOR,1570825,CDM,272,RC,,,Outpatient,,,945,756,,803.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,192.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,533.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,533.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,533.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,533.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,850.5,90,,,percent of total billed charges,90% of total billed charges,330.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,649.22,68.7,,,percent of total billed charges,68.7% of total billed charges,756,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,548.1,58,,,percent of total billed charges,58% of total billed charges,192.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,803.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,192.5,850.5,
HERPES SPINAL FLUID,3000150,CDM,300,RC,87530,HCPCS,Outpatient,,,950,760,,807.5,85,,,percent of total billed charges,85% of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,130,,,fee schedule,Pays 130% Medicare OPPS,193.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,536.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,536.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,536.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,536.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,43.69,102,,,fee schedule,Pays 102% Medicare OPPS,855,90,,,percent of total billed charges,90% of total billed charges,332.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,652.65,68.7,,,percent of total billed charges,68.7% of total billed charges,760,80,,,percent of total billed charges,80 percent of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,38.55,90,,,fee schedule,Pays 90% Medicare OPPS,551,58,,,percent of total billed charges,58% of total billed charges,193.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,130,,,fee schedule,Pays 130% Medicare OPPS,807.5,85,,,percent of total billed charges,85% of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,38.55,855,
CT 3-D RECON AT CT,4275377,CDM,350,RC,76376,HCPCS,Outpatient,,,950,760,,807.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,193.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,536.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,536.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,536.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,533.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,855,90,,,percent of total billed charges,90% of total billed charges,332.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,652.65,68.7,,,percent of total billed charges,68.7% of total billed charges,760,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,551,58,,,percent of total billed charges,58% of total billed charges,193.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,807.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,193.52,855,
US IMPOT PENILE STUDY PLETHYSMOGRAPHY,4654240,CDM,921,RC,54240,HCPCS,Outpatient,,,950,760,,807.5,85,,,percent of total billed charges,85% of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,320.22,130,,,fee schedule,Pays 130% Medicare OPPS,193.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,536.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,536.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,536.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,536.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,242.49,102,,,fee schedule,Pays 102% Medicare OPPS,855,90,,,percent of total billed charges,90% of total billed charges,332.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,652.65,68.7,,,percent of total billed charges,68.7% of total billed charges,760,80,,,percent of total billed charges,80 percent of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,213.96,90,,,fee schedule,Pays 90% Medicare OPPS,551,58,,,percent of total billed charges,58% of total billed charges,193.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,246.33,100,,,fee schedule,Pays 100% Medicare OPPS,320.22,130,,,fee schedule,Pays 130% Medicare OPPS,807.5,85,,,percent of total billed charges,85% of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,193.52,855,
STAPLER PURSTRING 45MM 020730,7950297,CDM,272,RC,,,Outpatient,,,950,760,,807.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,193.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,536.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,536.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,536.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,536.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,855,90,,,percent of total billed charges,90% of total billed charges,332.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,652.65,68.7,,,percent of total billed charges,68.7% of total billed charges,760,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,551,58,,,percent of total billed charges,58% of total billed charges,193.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,807.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,193.52,855,
RABIES IMMUNE GLOB 150UNIT/ML 2ML VIAL,2601041,CDM,636,RC,90375,HCPCS,Both,,,955,764,,811.75,85,,,percent of total billed charges,85% of total billed charges,213.24,100,,,fee schedule,Pays 100% Medicare OPPS,213.24,100,,,fee schedule,Pays 100% Medicare OPPS,213.24,100,,,fee schedule,Pays 100% Medicare OPPS,361.06,130,,,fee schedule,Pays 130% Medicare OPPS,256.68,120.37,,,fee schedule,120.37% of custom fee schedule,498.23,52.17,,,case rate,100% of BCBS case rate,498.23,52.17,,,case rate,100% of BCBS case rate,498.23,52.17,,,case rate,100% of BCBS case rate,498.23,52.17,,,case rate,100% of BCBS case rate,217.5,102,,,fee schedule,Pays 102% Medicare OPPS,859.5,90,,,percent of total billed charges,90% of total billed charges,266.93,125.18,,,fee schedule,125.18% of custom fee schedule,656.09,68.7,,,percent of total billed charges,68.7% of total billed charges,764,80,,,percent of total billed charges,80 percent of total billed charges,213.24,100,,,fee schedule,Pays 100% Medicare OPPS,191.91,90,,,fee schedule,Pays 90% Medicare OPPS,553.9,58,,,percent of total billed charges,58% of total billed charges,256.68,120.37,,,fee schedule,120.37% of custom fee schedule,277.74,100,,,fee schedule,Pays 100% Medicare OPPS,361.06,130,,,fee schedule,Pays 130% Medicare OPPS,811.75,85,,,percent of total billed charges,85% of total billed charges,213.24,100,,,fee schedule,Pays 100% Medicare OPPS,191.91,859.5,
LAC REPAIR SIMPLE 12.6 CM TO 20.0 CM,2012016,CDM,450,RC,12016,HCPCS,Outpatient,,,965,772,,820.25,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,196.57,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,545.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,545.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,545.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,545.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,316.7,102,,,fee schedule,Pays 102% Medicare OPPS,868.5,90,,,percent of total billed charges,90% of total billed charges,337.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,662.96,68.7,,,percent of total billed charges,68.7% of total billed charges,772,80,,,percent of total billed charges,80 percent of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,279.44,90,,,fee schedule,Pays 90% Medicare OPPS,559.7,58,,,percent of total billed charges,58% of total billed charges,196.57,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,328.14,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,820.25,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,196.57,868.5,
LAC INTER 20.1 CM - 30.0 CM,2012036,CDM,450,RC,12036,HCPCS,Outpatient,,,965,772,,820.25,85,,,percent of total billed charges,85% of total billed charges,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,664.28,130,,,fee schedule,Pays 130% Medicare OPPS,196.57,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,545.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,545.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,545.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,545.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,479.88,102,,,fee schedule,Pays 102% Medicare OPPS,868.5,90,,,percent of total billed charges,90% of total billed charges,337.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,662.96,68.7,,,percent of total billed charges,68.7% of total billed charges,772,80,,,percent of total billed charges,80 percent of total billed charges,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,423.42,90,,,fee schedule,Pays 90% Medicare OPPS,559.7,58,,,percent of total billed charges,58% of total billed charges,196.57,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,510.99,100,,,fee schedule,Pays 100% Medicare OPPS,664.28,130,,,fee schedule,Pays 130% Medicare OPPS,820.25,85,,,percent of total billed charges,85% of total billed charges,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,196.57,868.5,
Draining or injecting medication into a major joint/bursa without ultrasound,4000028,CDM,320,RC,20610,HCPCS,Outpatient,,,970,776,,824.5,85,,,percent of total billed charges,85% of total billed charges,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,310.88,130,,,fee schedule,Pays 130% Medicare OPPS,197.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,548.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,548.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,548.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,545.14,56.5,,,percent of total billed charges,56.5 percent of total billed charges,239.38,102,,,fee schedule,Pays 102% Medicare OPPS,873,90,,,percent of total billed charges,90% of total billed charges,339.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,666.39,68.7,,,percent of total billed charges,68.7% of total billed charges,776,80,,,percent of total billed charges,80 percent of total billed charges,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,211.22,90,,,fee schedule,Pays 90% Medicare OPPS,562.6,58,,,percent of total billed charges,58% of total billed charges,197.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,239.14,100,,,fee schedule,Pays 100% Medicare OPPS,310.88,130,,,fee schedule,Pays 130% Medicare OPPS,824.5,85,,,percent of total billed charges,85% of total billed charges,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,197.59,873,
Draining or injecting medication into a major joint/bursa without ultrasound,4020610,CDM,320,RC,20610,HCPCS,Outpatient,,,970,776,,824.5,85,,,percent of total billed charges,85% of total billed charges,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,310.88,130,,,fee schedule,Pays 130% Medicare OPPS,197.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,548.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,548.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,548.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,545.14,56.5,,,percent of total billed charges,56.5 percent of total billed charges,239.38,102,,,fee schedule,Pays 102% Medicare OPPS,873,90,,,percent of total billed charges,90% of total billed charges,339.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,666.39,68.7,,,percent of total billed charges,68.7% of total billed charges,776,80,,,percent of total billed charges,80 percent of total billed charges,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,211.22,90,,,fee schedule,Pays 90% Medicare OPPS,562.6,58,,,percent of total billed charges,58% of total billed charges,197.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,239.14,100,,,fee schedule,Pays 100% Medicare OPPS,310.88,130,,,fee schedule,Pays 130% Medicare OPPS,824.5,85,,,percent of total billed charges,85% of total billed charges,234.69,100,,,fee schedule,Pays 100% Medicare OPPS,197.59,873,
NM LIVER/SPLEEN (NO SPECT),4578215,CDM,341,RC,78215,HCPCS,Outpatient,,,970,776,,824.5,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,197.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,548.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,548.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,548.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,548.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,345.39,102,,,fee schedule,Pays 102% Medicare OPPS,873,90,,,percent of total billed charges,90% of total billed charges,339.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,666.39,68.7,,,percent of total billed charges,68.7% of total billed charges,776,80,,,percent of total billed charges,80 percent of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,304.76,90,,,fee schedule,Pays 90% Medicare OPPS,562.6,58,,,percent of total billed charges,58% of total billed charges,197.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,341.87,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,824.5,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,197.59,873,
DRILL BIT,7901119,CDM,272,RC,,,Outpatient,,,970,776,,824.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,197.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,548.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,548.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,548.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,548.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,873,90,,,percent of total billed charges,90% of total billed charges,339.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,666.39,68.7,,,percent of total billed charges,68.7% of total billed charges,776,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,562.6,58,,,percent of total billed charges,58% of total billed charges,197.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,824.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,197.59,873,
I & D ABSCESS COMPLIATED,1010061,CDM,762,RC,,,Outpatient,,,975,780,,828.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,198.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,550.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,550.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,550.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,550.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,877.5,90,,,percent of total billed charges,90% of total billed charges,341.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,669.83,68.7,,,percent of total billed charges,68.7% of total billed charges,780,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,565.5,58,,,percent of total billed charges,58% of total billed charges,198.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,828.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,198.61,877.5,
OR ACUITY LEVEL IV X 15 MIN,1501156,CDM,360,RC,,,Outpatient,,,975,780,,828.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,198.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,550.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,550.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,550.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,550.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,877.5,90,,,percent of total billed charges,90% of total billed charges,341.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,669.83,68.7,,,percent of total billed charges,68.7% of total billed charges,780,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,565.5,58,,,percent of total billed charges,58% of total billed charges,198.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,828.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,198.61,877.5,
XR OPER CHOLANGIOGRAM,4074300,CDM,320,RC,74300,HCPCS,Outpatient,,,975,780,,828.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,198.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,550.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,550.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,550.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,547.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,877.5,90,,,percent of total billed charges,90% of total billed charges,341.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,669.83,68.7,,,percent of total billed charges,68.7% of total billed charges,780,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,565.5,58,,,percent of total billed charges,58% of total billed charges,198.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,828.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,198.61,877.5,
Ultrasound of back wall of the abdomen with limited areas viewed,4676770,CDM,402,RC,76775,HCPCS,Outpatient,,,975,780,,828.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,198.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,550.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,550.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,550.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,547.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,877.5,90,,,percent of total billed charges,90% of total billed charges,341.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,669.83,68.7,,,percent of total billed charges,68.7% of total billed charges,780,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,565.5,58,,,percent of total billed charges,58% of total billed charges,198.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,828.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,877.5,
Ultrasound of back wall of the abdomen with limited areas viewed,4676771,CDM,402,RC,76775,HCPCS,Outpatient,,,975,780,,828.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,198.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,550.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,550.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,550.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,547.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,877.5,90,,,percent of total billed charges,90% of total billed charges,341.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,669.83,68.7,,,percent of total billed charges,68.7% of total billed charges,780,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,565.5,58,,,percent of total billed charges,58% of total billed charges,198.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,828.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,877.5,
Ultrasound of back wall of the abdomen with limited areas viewed,4676775,CDM,402,RC,76775,HCPCS,Outpatient,,,975,780,,828.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,198.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,550.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,550.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,550.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,547.95,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,877.5,90,,,percent of total billed charges,90% of total billed charges,341.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,669.83,68.7,,,percent of total billed charges,68.7% of total billed charges,780,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,565.5,58,,,percent of total billed charges,58% of total billed charges,198.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,828.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,877.5,
PROBE FIAPC STRAIGHT FIRE FLEXIBLE,1750020,CDM,272,RC,,,Outpatient,,,985,788,,837.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,200.64,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,556.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,556.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,556.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,556.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,886.5,90,,,percent of total billed charges,90% of total billed charges,344.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,676.7,68.7,,,percent of total billed charges,68.7% of total billed charges,788,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,571.3,58,,,percent of total billed charges,58% of total billed charges,200.64,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,837.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,200.64,886.5,
LAC SIMPLE 20.1-30CM,2012006,CDM,450,RC,12006,HCPCS,Outpatient,,,990,792,,841.5,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,201.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,559.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,559.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,559.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,559.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,316.7,102,,,fee schedule,Pays 102% Medicare OPPS,891,90,,,percent of total billed charges,90% of total billed charges,346.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,680.13,68.7,,,percent of total billed charges,68.7% of total billed charges,792,80,,,percent of total billed charges,80 percent of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,279.44,90,,,fee schedule,Pays 90% Medicare OPPS,574.2,58,,,percent of total billed charges,58% of total billed charges,201.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,328.14,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,841.5,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,201.66,891,
CL TX ULNAR SHFT W/ MANIPULATION,2025535,CDM,450,RC,25535,HCPCS,Outpatient,,,990,792,,841.5,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,201.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,559.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,559.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,559.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,559.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,188.85,102,,,fee schedule,Pays 102% Medicare OPPS,891,90,,,percent of total billed charges,90% of total billed charges,346.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,680.13,68.7,,,percent of total billed charges,68.7% of total billed charges,792,80,,,percent of total billed charges,80 percent of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,166.63,90,,,fee schedule,Pays 90% Medicare OPPS,574.2,58,,,percent of total billed charges,58% of total billed charges,201.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,182.08,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,841.5,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,166.63,891,
NM TESTICULAR SCAN,4578761,CDM,341,RC,78761,HCPCS,Outpatient,,,990,792,,841.5,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,201.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,559.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,559.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,559.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,559.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,345.39,102,,,fee schedule,Pays 102% Medicare OPPS,891,90,,,percent of total billed charges,90% of total billed charges,346.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,680.13,68.7,,,percent of total billed charges,68.7% of total billed charges,792,80,,,percent of total billed charges,80 percent of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,304.76,90,,,fee schedule,Pays 90% Medicare OPPS,574.2,58,,,percent of total billed charges,58% of total billed charges,201.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,341.87,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,841.5,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,201.66,891,
Abdominal ultrasound of pregnant uterus (less than 14 weeks) single or first fetus,4676801,CDM,402,RC,76801,HCPCS,Outpatient,,,990,792,,841.5,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,201.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,559.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,559.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,559.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,556.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,891,90,,,percent of total billed charges,90% of total billed charges,346.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,680.13,68.7,,,percent of total billed charges,68.7% of total billed charges,792,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,574.2,58,,,percent of total billed charges,58% of total billed charges,201.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,841.5,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,891,
Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus,4676805,CDM,402,RC,76805,HCPCS,Outpatient,,,990,792,,841.5,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,201.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,559.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,559.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,559.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,556.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,891,90,,,percent of total billed charges,90% of total billed charges,346.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,680.13,68.7,,,percent of total billed charges,68.7% of total billed charges,792,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,574.2,58,,,percent of total billed charges,58% of total billed charges,201.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,841.5,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,891,
LIGATOR SAEED MULTI-BAND SIX SHOOTER,1750013,CDM,272,RC,,,Outpatient,,,995,796,,845.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,202.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,562.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,562.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,562.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,562.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,895.5,90,,,percent of total billed charges,90% of total billed charges,348.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,683.57,68.7,,,percent of total billed charges,68.7% of total billed charges,796,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,577.1,58,,,percent of total billed charges,58% of total billed charges,202.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,845.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,202.68,895.5,
NAIL REMOVAL,2011750,CDM,450,RC,11750,HCPCS,Outpatient,,,995,796,,845.75,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,202.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,562.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,562.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,562.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,562.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,316.7,102,,,fee schedule,Pays 102% Medicare OPPS,895.5,90,,,percent of total billed charges,90% of total billed charges,348.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,683.57,68.7,,,percent of total billed charges,68.7% of total billed charges,796,80,,,percent of total billed charges,80 percent of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,279.44,90,,,fee schedule,Pays 90% Medicare OPPS,577.1,58,,,percent of total billed charges,58% of total billed charges,202.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,328.14,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,845.75,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,202.68,895.5,
FB REMOVAL MUSCLE,2020520,CDM,450,RC,20520,HCPCS,Outpatient,,,995,796,,845.75,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,202.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,562.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,562.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,562.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,562.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1289.21,102,,,fee schedule,Pays 102% Medicare OPPS,895.5,90,,,percent of total billed charges,90% of total billed charges,348.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,683.57,68.7,,,percent of total billed charges,68.7% of total billed charges,796,80,,,percent of total billed charges,80 percent of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1137.55,90,,,fee schedule,Pays 90% Medicare OPPS,577.1,58,,,percent of total billed charges,58% of total billed charges,202.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1318.97,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,845.75,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,202.68,1714.66,
MARLEX MESH 3 X 6,7905867,CDM,278,RC,,,Both,,,995,796,,845.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,202.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,895.5,90,,,percent of total billed charges,90% of total billed charges,348.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,683.57,68.7,,,percent of total billed charges,68.7% of total billed charges,796,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,577.1,58,,,percent of total billed charges,58% of total billed charges,202.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,845.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,895.5,
STAPLER CURVED INTRALUMINAL ECS33A,7950290,CDM,272,RC,,,Outpatient,,,1000,800,,850,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,203.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,565,56.5,,,percent of total billed charges,56.5 percent of total billed charges,565,56.5,,,percent of total billed charges,56.5 percent of total billed charges,565,56.5,,,percent of total billed charges,56.5 percent of total billed charges,565,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,900,90,,,percent of total billed charges,90% of total billed charges,350,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,687,68.7,,,percent of total billed charges,68.7% of total billed charges,800,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,580,58,,,percent of total billed charges,58% of total billed charges,203.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,850,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,203.7,900,
"Flouroscopy, or x-ray ""movie"" that takes less than an hour",4070370,CDM,320,RC,76000,HCPCS,Outpatient,,,1010,808,,858.5,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,205.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,570.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,570.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,570.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,567.62,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,909,90,,,percent of total billed charges,90% of total billed charges,353.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,693.87,68.7,,,percent of total billed charges,68.7% of total billed charges,808,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,585.8,58,,,percent of total billed charges,58% of total billed charges,205.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,858.5,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,909,
XR FLUROSCOPY OF LARYNX,4076001,CDM,320,RC,70370,HCPCS,Outpatient,,,1010,808,,858.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,205.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,570.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,570.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,570.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,567.62,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,909,90,,,percent of total billed charges,90% of total billed charges,353.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,693.87,68.7,,,percent of total billed charges,68.7% of total billed charges,808,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,585.8,58,,,percent of total billed charges,58% of total billed charges,205.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,858.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,909,
CT 3-D IND/WK STATION,4273705,CDM,352,RC,76377,HCPCS,Outpatient,,,1010,808,,858.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,205.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,570.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,570.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,570.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,567.62,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,909,90,,,percent of total billed charges,90% of total billed charges,353.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,693.87,68.7,,,percent of total billed charges,68.7% of total billed charges,808,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,585.8,58,,,percent of total billed charges,58% of total billed charges,205.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,858.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,205.74,909,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,4676705,CDM,402,RC,76705,HCPCS,Outpatient,,,1010,808,,858.5,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,205.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,570.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,570.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,570.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,567.62,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,909,90,,,percent of total billed charges,90% of total billed charges,353.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,693.87,68.7,,,percent of total billed charges,68.7% of total billed charges,808,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,585.8,58,,,percent of total billed charges,58% of total billed charges,205.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,858.5,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,909,
.......HOLTER SCANS,5693226,CDM,731,RC,93226,HCPCS,Outpatient,,,1010,808,,858.5,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,205.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,570.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,570.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,570.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,570.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,909,90,,,percent of total billed charges,90% of total billed charges,353.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,693.87,68.7,,,percent of total billed charges,68.7% of total billed charges,808,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,585.8,58,,,percent of total billed charges,58% of total billed charges,205.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,858.5,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,909,
STAPLER LOADING UNIT,7950119,CDM,270,RC,,,Outpatient,,,1010,808,,858.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,205.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,570.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,570.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,570.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,570.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,909,90,,,percent of total billed charges,90% of total billed charges,353.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,693.87,68.7,,,percent of total billed charges,68.7% of total billed charges,808,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,585.8,58,,,percent of total billed charges,58% of total billed charges,205.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,858.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,205.74,909,
ENDO GIA 30V STAPLER,7905845,CDM,270,RC,,,Outpatient,,,1015,812,,862.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,206.76,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,573.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,573.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,573.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,573.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,913.5,90,,,percent of total billed charges,90% of total billed charges,355.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,697.31,68.7,,,percent of total billed charges,68.7% of total billed charges,812,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,588.7,58,,,percent of total billed charges,58% of total billed charges,206.76,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,862.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,206.76,913.5,
INTUBATION EMERGENCY,2031500,CDM,450,RC,31500,HCPCS,Outpatient,,,1020,816,,867,85,,,percent of total billed charges,85% of total billed charges,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,237.63,130,,,fee schedule,Pays 130% Medicare OPPS,207.77,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,576.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,576.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,576.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,576.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,193.85,102,,,fee schedule,Pays 102% Medicare OPPS,918,90,,,percent of total billed charges,90% of total billed charges,357,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,700.74,68.7,,,percent of total billed charges,68.7% of total billed charges,816,80,,,percent of total billed charges,80 percent of total billed charges,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,171.04,90,,,fee schedule,Pays 90% Medicare OPPS,591.6,58,,,percent of total billed charges,58% of total billed charges,207.77,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,182.8,100,,,fee schedule,Pays 100% Medicare OPPS,237.63,130,,,fee schedule,Pays 130% Medicare OPPS,867,85,,,percent of total billed charges,85% of total billed charges,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,171.04,918,
CPR,2092950,CDM,450,RC,92950,HCPCS,Outpatient,,,1020,816,,867,85,,,percent of total billed charges,85% of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,320.22,130,,,fee schedule,Pays 130% Medicare OPPS,207.77,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,576.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,576.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,576.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,576.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,242.49,102,,,fee schedule,Pays 102% Medicare OPPS,918,90,,,percent of total billed charges,90% of total billed charges,357,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,700.74,68.7,,,percent of total billed charges,68.7% of total billed charges,816,80,,,percent of total billed charges,80 percent of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,213.96,90,,,fee schedule,Pays 90% Medicare OPPS,591.6,58,,,percent of total billed charges,58% of total billed charges,207.77,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,246.33,100,,,fee schedule,Pays 100% Medicare OPPS,320.22,130,,,fee schedule,Pays 130% Medicare OPPS,867,85,,,percent of total billed charges,85% of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,207.77,918,
US CYST ASPIRATION,4619000,CDM,402,RC,19000,HCPCS,Outpatient,,,1020,816,,867,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,742.06,130,,,fee schedule,Pays 130% Medicare OPPS,207.77,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,576.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,576.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,576.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,573.24,56.5,,,percent of total billed charges,56.5 percent of total billed charges,570.17,102,,,fee schedule,Pays 102% Medicare OPPS,918,90,,,percent of total billed charges,90% of total billed charges,357,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,700.74,68.7,,,percent of total billed charges,68.7% of total billed charges,816,80,,,percent of total billed charges,80 percent of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,503.1,90,,,fee schedule,Pays 90% Medicare OPPS,591.6,58,,,percent of total billed charges,58% of total billed charges,207.77,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,570.82,100,,,fee schedule,Pays 100% Medicare OPPS,742.06,130,,,fee schedule,Pays 130% Medicare OPPS,867,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,207.77,918,
INTUBATION,5531500,CDM,410,RC,31500,HCPCS,Outpatient,,,1020,816,,867,85,,,percent of total billed charges,85% of total billed charges,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,237.63,130,,,fee schedule,Pays 130% Medicare OPPS,207.77,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,576.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,576.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,576.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,576.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,193.85,102,,,fee schedule,Pays 102% Medicare OPPS,918,90,,,percent of total billed charges,90% of total billed charges,357,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,700.74,68.7,,,percent of total billed charges,68.7% of total billed charges,816,80,,,percent of total billed charges,80 percent of total billed charges,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,171.04,90,,,fee schedule,Pays 90% Medicare OPPS,591.6,58,,,percent of total billed charges,58% of total billed charges,207.77,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,182.8,100,,,fee schedule,Pays 100% Medicare OPPS,237.63,130,,,fee schedule,Pays 130% Medicare OPPS,867,85,,,percent of total billed charges,85% of total billed charges,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,171.04,918,
RC PRBC UNIT,3109021,CDM,390,RC,P9021,HCPCS,Outpatient,,,1035,828,,879.75,85,,,percent of total billed charges,85% of total billed charges,140.53,100,,,fee schedule,Pays 100% Medicare OPPS,140.53,100,,,fee schedule,Pays 100% Medicare OPPS,140.53,100,,,fee schedule,Pays 100% Medicare OPPS,176.17,130,,,fee schedule,Pays 130% Medicare OPPS,210.83,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,584.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,584.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,584.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,584.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,143.34,102,,,fee schedule,Pays 102% Medicare OPPS,931.5,90,,,percent of total billed charges,90% of total billed charges,362.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,711.05,68.7,,,percent of total billed charges,68.7% of total billed charges,828,80,,,percent of total billed charges,80 percent of total billed charges,140.53,100,,,fee schedule,Pays 100% Medicare OPPS,126.47,90,,,fee schedule,Pays 90% Medicare OPPS,600.3,58,,,percent of total billed charges,58% of total billed charges,210.83,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,135.52,100,,,fee schedule,Pays 100% Medicare OPPS,176.17,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,140.53,100,,,fee schedule,Pays 100% Medicare OPPS,126.47,931.5,
SB LEUKO-REDUC PRBC UNIT,3109040,CDM,390,RC,P9016,HCPCS,Outpatient,,,1035,828,,879.75,85,,,percent of total billed charges,85% of total billed charges,192.39,100,,,fee schedule,Pays 100% Medicare OPPS,192.39,100,,,fee schedule,Pays 100% Medicare OPPS,192.39,100,,,fee schedule,Pays 100% Medicare OPPS,245.97,130,,,fee schedule,Pays 130% Medicare OPPS,210.83,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,584.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,584.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,584.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,584.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,196.23,102,,,fee schedule,Pays 102% Medicare OPPS,931.5,90,,,percent of total billed charges,90% of total billed charges,362.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,711.05,68.7,,,percent of total billed charges,68.7% of total billed charges,828,80,,,percent of total billed charges,80 percent of total billed charges,192.39,100,,,fee schedule,Pays 100% Medicare OPPS,173.15,90,,,fee schedule,Pays 90% Medicare OPPS,600.3,58,,,percent of total billed charges,58% of total billed charges,210.83,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,189.21,100,,,fee schedule,Pays 100% Medicare OPPS,245.97,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,192.39,100,,,fee schedule,Pays 100% Medicare OPPS,173.15,931.5,
DRILL BIT 12MM,1570351,CDM,278,RC,A4649,HCPCS,Both,,,1040,832,,884,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,211.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,936,90,,,percent of total billed charges,90% of total billed charges,364,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,714.48,68.7,,,percent of total billed charges,68.7% of total billed charges,832,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,603.2,58,,,percent of total billed charges,58% of total billed charges,211.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,884,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,936,
RESOLUTION CLIP 360 M00521230,1750065,CDM,272,RC,,,Outpatient,,,1040,832,,884,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,211.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,587.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,587.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,587.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,587.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,936,90,,,percent of total billed charges,90% of total billed charges,364,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,714.48,68.7,,,percent of total billed charges,68.7% of total billed charges,832,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,603.2,58,,,percent of total billed charges,58% of total billed charges,211.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,884,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,211.85,936,
RESOLUTION CLIP 360 M00521231,1750067,CDM,272,RC,,,Outpatient,,,1040,832,,884,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,211.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,587.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,587.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,587.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,587.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,936,90,,,percent of total billed charges,90% of total billed charges,364,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,714.48,68.7,,,percent of total billed charges,68.7% of total billed charges,832,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,603.2,58,,,percent of total billed charges,58% of total billed charges,211.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,884,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,211.85,936,
FB REMOVAL FOREIGN,2010120,CDM,450,RC,,,Outpatient,,,1040,832,,884,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,211.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,587.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,587.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,587.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,587.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,936,90,,,percent of total billed charges,90% of total billed charges,364,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,714.48,68.7,,,percent of total billed charges,68.7% of total billed charges,832,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,603.2,58,,,percent of total billed charges,58% of total billed charges,211.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,884,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,211.85,936,
CL TX POST HIP DL WO ANESTHESIA,2027265,CDM,450,RC,27265,HCPCS,Outpatient,,,1040,832,,884,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,211.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,587.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,587.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,587.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,587.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,188.85,102,,,fee schedule,Pays 102% Medicare OPPS,936,90,,,percent of total billed charges,90% of total billed charges,364,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,714.48,68.7,,,percent of total billed charges,68.7% of total billed charges,832,80,,,percent of total billed charges,80 percent of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,166.63,90,,,fee schedule,Pays 90% Medicare OPPS,603.2,58,,,percent of total billed charges,58% of total billed charges,211.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,182.08,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,884,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,166.63,936,
BLEPHAROTOMY DRAIN ABSC EYELID,2067700,CDM,450,RC,67700,HCPCS,Outpatient,,,1040,832,,884,85,,,percent of total billed charges,85% of total billed charges,234.98,100,,,fee schedule,Pays 100% Medicare OPPS,234.98,100,,,fee schedule,Pays 100% Medicare OPPS,234.98,100,,,fee schedule,Pays 100% Medicare OPPS,302.68,130,,,fee schedule,Pays 130% Medicare OPPS,211.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,587.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,587.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,587.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,587.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,239.68,102,,,fee schedule,Pays 102% Medicare OPPS,936,90,,,percent of total billed charges,90% of total billed charges,364,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,714.48,68.7,,,percent of total billed charges,68.7% of total billed charges,832,80,,,percent of total billed charges,80 percent of total billed charges,234.98,100,,,fee schedule,Pays 100% Medicare OPPS,211.48,90,,,fee schedule,Pays 90% Medicare OPPS,603.2,58,,,percent of total billed charges,58% of total billed charges,211.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,232.82,100,,,fee schedule,Pays 100% Medicare OPPS,302.68,130,,,fee schedule,Pays 130% Medicare OPPS,884,85,,,percent of total billed charges,85% of total billed charges,234.98,100,,,fee schedule,Pays 100% Medicare OPPS,211.48,936,
***DO NOT USE***,7950214,CDM,270,RC,,,Outpatient,,,1040,832,,884,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,211.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,587.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,587.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,587.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,587.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,936,90,,,percent of total billed charges,90% of total billed charges,364,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,714.48,68.7,,,percent of total billed charges,68.7% of total billed charges,832,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,603.2,58,,,percent of total billed charges,58% of total billed charges,211.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,884,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,211.85,936,
LENS INTRAOCULAR SN6AT4 13.5,1570197,CDM,276,RC,V2797,HCPCS,Outpatient,,,1045,836,,888.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,940.5,90,,,percent of total billed charges,90% of total billed charges,365.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,717.92,68.7,,,percent of total billed charges,68.7% of total billed charges,836,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,606.1,58,,,percent of total billed charges,58% of total billed charges,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,888.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,940.5,
LENS INTRAOCULAR SN6AT4 14.5,1570198,CDM,276,RC,V2797,HCPCS,Outpatient,,,1045,836,,888.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,940.5,90,,,percent of total billed charges,90% of total billed charges,365.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,717.92,68.7,,,percent of total billed charges,68.7% of total billed charges,836,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,606.1,58,,,percent of total billed charges,58% of total billed charges,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,888.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,940.5,
LENS INTRAOCULAR SN6AT4 15.0,1570207,CDM,276,RC,V2797,HCPCS,Outpatient,,,1045,836,,888.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,940.5,90,,,percent of total billed charges,90% of total billed charges,365.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,717.92,68.7,,,percent of total billed charges,68.7% of total billed charges,836,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,606.1,58,,,percent of total billed charges,58% of total billed charges,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,888.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,940.5,
LENS INTRAOCULAR SN6AT4 13.0,1570208,CDM,276,RC,V2797,HCPCS,Outpatient,,,1045,836,,888.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,940.5,90,,,percent of total billed charges,90% of total billed charges,365.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,717.92,68.7,,,percent of total billed charges,68.7% of total billed charges,836,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,606.1,58,,,percent of total billed charges,58% of total billed charges,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,888.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,940.5,
LENS INTRAOCULAR SN6AT5 24.5,1570209,CDM,276,RC,V2797,HCPCS,Outpatient,,,1045,836,,888.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,940.5,90,,,percent of total billed charges,90% of total billed charges,365.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,717.92,68.7,,,percent of total billed charges,68.7% of total billed charges,836,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,606.1,58,,,percent of total billed charges,58% of total billed charges,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,888.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,940.5,
LENS INTRAOCULAR SN6AT4 27.5,1570210,CDM,276,RC,V2797,HCPCS,Outpatient,,,1045,836,,888.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,0.01,,,,case rate,Not reimbursable per contract ,,,,,other,Not reimbursable per contract,940.5,90,,,percent of total billed charges,90% of total billed charges,365.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,717.92,68.7,,,percent of total billed charges,68.7% of total billed charges,836,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,606.1,58,,,percent of total billed charges,58% of total billed charges,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,888.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,940.5,
.CHROM ANAL15-20(CHROM7&11,3000049,CDM,311,RC,88262,HCPCS,Outpatient,,,1045,836,,888.25,85,,,percent of total billed charges,85% of total billed charges,125.49,100,,,fee schedule,Pays 100% Medicare OPPS,125.49,100,,,fee schedule,Pays 100% Medicare OPPS,125.49,100,,,fee schedule,Pays 100% Medicare OPPS,163.13,130,,,fee schedule,Pays 130% Medicare OPPS,188.66,120.37,,,fee schedule,120.37% of custom fee schedule,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,127.99,102,,,fee schedule,Pays 102% Medicare OPPS,940.5,90,,,percent of total billed charges,90% of total billed charges,196.19,125.18,,,fee schedule,125.18% of custom fee schedule,717.92,68.7,,,percent of total billed charges,68.7% of total billed charges,836,80,,,percent of total billed charges,80 percent of total billed charges,125.49,100,,,fee schedule,Pays 100% Medicare OPPS,112.94,90,,,fee schedule,Pays 90% Medicare OPPS,606.1,58,,,percent of total billed charges,58% of total billed charges,188.66,120.37,,,fee schedule,120.37% of custom fee schedule,125.49,100,,,fee schedule,Pays 100% Medicare OPPS,163.13,130,,,fee schedule,Pays 130% Medicare OPPS,888.25,85,,,percent of total billed charges,85% of total billed charges,125.49,100,,,fee schedule,Pays 100% Medicare OPPS,112.94,940.5,
.PRADER-WILLI BY FISH-A,3088230,CDM,311,RC,88230,HCPCS,Outpatient,,,1045,836,,888.25,85,,,percent of total billed charges,85% of total billed charges,116.49,100,,,fee schedule,Pays 100% Medicare OPPS,116.49,100,,,fee schedule,Pays 100% Medicare OPPS,116.49,100,,,fee schedule,Pays 100% Medicare OPPS,151.43,130,,,fee schedule,Pays 130% Medicare OPPS,176.33,120.37,,,fee schedule,120.37% of custom fee schedule,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.81,102,,,fee schedule,Pays 102% Medicare OPPS,940.5,90,,,percent of total billed charges,90% of total billed charges,183.38,125.18,,,fee schedule,125.18% of custom fee schedule,717.92,68.7,,,percent of total billed charges,68.7% of total billed charges,836,80,,,percent of total billed charges,80 percent of total billed charges,116.49,100,,,fee schedule,Pays 100% Medicare OPPS,104.84,90,,,fee schedule,Pays 90% Medicare OPPS,606.1,58,,,percent of total billed charges,58% of total billed charges,176.33,120.37,,,fee schedule,120.37% of custom fee schedule,116.49,100,,,fee schedule,Pays 100% Medicare OPPS,151.43,130,,,fee schedule,Pays 130% Medicare OPPS,888.25,85,,,percent of total billed charges,85% of total billed charges,116.49,100,,,fee schedule,Pays 100% Medicare OPPS,104.84,940.5,
.CHROM ANAL20-25(CHROM7&11,3088264,CDM,311,RC,88264,HCPCS,Outpatient,,,1045,836,,888.25,85,,,percent of total billed charges,85% of total billed charges,144.61,100,,,fee schedule,Pays 100% Medicare OPPS,144.61,100,,,fee schedule,Pays 100% Medicare OPPS,144.61,100,,,fee schedule,Pays 100% Medicare OPPS,187.99,130,APC,,fee schedule,Pays 130% Medicare OPPS,188.66,120.37,,,fee schedule,120.37% of custom fee schedule,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,147.5,102,,,fee schedule,Pays 102% Medicare OPPS,940.5,90,,,percent of total billed charges,90% of total billed charges,196.19,125.18,,,fee schedule,125.18% of custom fee schedule,717.92,68.7,,,percent of total billed charges,68.7% of total billed charges,836,80,,,percent of total billed charges,80 percent of total billed charges,144.61,100,,,fee schedule,Pays 100% Medicare OPPS,130.14,90,,,fee schedule,Pays 90% Medicare OPPS,606.1,58,,,percent of total billed charges,58% of total billed charges,188.66,120.37,,,fee schedule,120.37% of custom fee schedule,144.61,100,,,fee schedule,Pays 100% Medicare OPPS,187.99,130,APC,,fee schedule,Pays 130% Medicare OPPS,888.25,85,,,percent of total billed charges,85% of total billed charges,144.61,100,,,fee schedule,Pays 100% Medicare OPPS,130.14,940.5,
XR RIBS BILAT W PA CHEST 4 VIEWS,4071111,CDM,320,RC,71111,HCPCS,Outpatient,,,1045,836,,888.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,587.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,940.5,90,,,percent of total billed charges,90% of total billed charges,365.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,717.92,68.7,,,percent of total billed charges,68.7% of total billed charges,836,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,606.1,58,,,percent of total billed charges,58% of total billed charges,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,888.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,940.5,
XR ARTHROGRAM SHOULDER,4073040,CDM,322,RC,73040,HCPCS,Outpatient,,,1045,836,,888.25,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.28,130,,,fee schedule,Pays 130% Medicare OPPS,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,587.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,940.5,90,,,percent of total billed charges,90% of total billed charges,365.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,717.92,68.7,,,percent of total billed charges,68.7% of total billed charges,836,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,606.1,58,,,percent of total billed charges,58% of total billed charges,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.28,130,,,fee schedule,Pays 130% Medicare OPPS,888.25,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,212.87,940.5,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,4600004,CDM,402,RC,76705,HCPCS,Outpatient,,,1045,836,,888.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,587.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,940.5,90,,,percent of total billed charges,90% of total billed charges,365.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,717.92,68.7,,,percent of total billed charges,68.7% of total billed charges,836,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,606.1,58,,,percent of total billed charges,58% of total billed charges,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,888.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,940.5,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,4600005,CDM,402,RC,76705,HCPCS,Outpatient,,,1045,836,,888.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,587.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,940.5,90,,,percent of total billed charges,90% of total billed charges,365.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,717.92,68.7,,,percent of total billed charges,68.7% of total billed charges,836,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,606.1,58,,,percent of total billed charges,58% of total billed charges,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,888.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,940.5,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,4600006,CDM,402,RC,76705,HCPCS,Outpatient,,,1045,836,,888.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,587.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,940.5,90,,,percent of total billed charges,90% of total billed charges,365.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,717.92,68.7,,,percent of total billed charges,68.7% of total billed charges,836,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,606.1,58,,,percent of total billed charges,58% of total billed charges,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,888.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,940.5,
US BIL PHYSOLOGIC SEG AR,4600013,CDM,921,RC,93923,HCPCS,Outpatient,,,1045,836,,888.25,85,,,percent of total billed charges,85% of total billed charges,125.42,100,,,fee schedule,Pays 100% Medicare OPPS,125.42,100,,,fee schedule,Pays 100% Medicare OPPS,125.42,100,,,fee schedule,Pays 100% Medicare OPPS,166.28,130,,,fee schedule,Pays 130% Medicare OPPS,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,127.92,102,,,fee schedule,Pays 102% Medicare OPPS,940.5,90,,,percent of total billed charges,90% of total billed charges,365.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,717.92,68.7,,,percent of total billed charges,68.7% of total billed charges,836,80,,,percent of total billed charges,80 percent of total billed charges,125.42,100,,,fee schedule,Pays 100% Medicare OPPS,112.87,90,,,fee schedule,Pays 90% Medicare OPPS,606.1,58,,,percent of total billed charges,58% of total billed charges,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,127.91,100,,,fee schedule,Pays 100% Medicare OPPS,166.28,130,,,fee schedule,Pays 130% Medicare OPPS,888.25,85,,,percent of total billed charges,85% of total billed charges,125.42,100,,,fee schedule,Pays 100% Medicare OPPS,112.87,940.5,
US AORTIC LOW EXT-LEFT,4600016,CDM,921,RC,93926,HCPCS,Outpatient,,,1045,836,,888.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,940.5,90,,,percent of total billed charges,90% of total billed charges,365.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,717.92,68.7,,,percent of total billed charges,68.7% of total billed charges,836,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,606.1,58,,,percent of total billed charges,58% of total billed charges,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,888.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,940.5,
US UPPER ARTERIAL-LEFT,4600017,CDM,921,RC,93931,HCPCS,Outpatient,,,1045,836,,888.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,940.5,90,,,percent of total billed charges,90% of total billed charges,365.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,717.92,68.7,,,percent of total billed charges,68.7% of total billed charges,836,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,606.1,58,,,percent of total billed charges,58% of total billed charges,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,888.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,940.5,
Complete ultrasound of the pelvis,4607685,CDM,402,RC,76856,HCPCS,Outpatient,,,1045,836,,888.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,587.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,940.5,90,,,percent of total billed charges,90% of total billed charges,365.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,717.92,68.7,,,percent of total billed charges,68.7% of total billed charges,836,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,606.1,58,,,percent of total billed charges,58% of total billed charges,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,888.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,940.5,
Complete ultrasound of the pelvis,4676856,CDM,402,RC,76856,HCPCS,Outpatient,,,1045,836,,888.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,587.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,940.5,90,,,percent of total billed charges,90% of total billed charges,365.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,717.92,68.7,,,percent of total billed charges,68.7% of total billed charges,836,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,606.1,58,,,percent of total billed charges,58% of total billed charges,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,888.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,940.5,
US GUIDANCE INTRAOPERATIVE,4676986,CDM,402,RC,76998,HCPCS,Outpatient,,,1045,836,,888.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,587.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,940.5,90,,,percent of total billed charges,90% of total billed charges,365.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,717.92,68.7,,,percent of total billed charges,68.7% of total billed charges,836,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,606.1,58,,,percent of total billed charges,58% of total billed charges,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,888.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,212.87,940.5,
US AORTIC LOW EXT-RIGHT,4693926,CDM,921,RC,93926,HCPCS,Outpatient,,,1045,836,,888.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,940.5,90,,,percent of total billed charges,90% of total billed charges,365.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,717.92,68.7,,,percent of total billed charges,68.7% of total billed charges,836,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,606.1,58,,,percent of total billed charges,58% of total billed charges,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,888.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,940.5,
US UPPER ARTERIAL-RIGHT,4693931,CDM,921,RC,93931,HCPCS,Outpatient,,,1045,836,,888.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,940.5,90,,,percent of total billed charges,90% of total billed charges,365.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,717.92,68.7,,,percent of total billed charges,68.7% of total billed charges,836,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,606.1,58,,,percent of total billed charges,58% of total billed charges,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,888.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,940.5,
US ARTERIAL-SCROTAL,4693975,CDM,921,RC,93975,HCPCS,Outpatient,,,1045,836,,888.25,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,940.5,90,,,percent of total billed charges,90% of total billed charges,365.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,717.92,68.7,,,percent of total billed charges,68.7% of total billed charges,836,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,606.1,58,,,percent of total billed charges,58% of total billed charges,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,888.25,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,940.5,
US DUPLX AORTA/IVC/LIMIT,4693979,CDM,921,RC,93979,HCPCS,Outpatient,,,1045,836,,888.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,590.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,940.5,90,,,percent of total billed charges,90% of total billed charges,365.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,717.92,68.7,,,percent of total billed charges,68.7% of total billed charges,836,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,606.1,58,,,percent of total billed charges,58% of total billed charges,212.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,888.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,940.5,
General health panel,3080050,CDM,301,RC,80050,HCPCS,Outpatient,,,1060,848,,901,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,215.92,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,598.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,598.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,598.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,598.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,954,90,,,percent of total billed charges,90% of total billed charges,371,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,728.22,68.7,,,percent of total billed charges,68.7% of total billed charges,848,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,614.8,58,,,percent of total billed charges,58% of total billed charges,215.92,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,901,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,215.92,954,
RI ANTIBODIES,3000259,CDM,301,RC,84182,HCPCS,Outpatient,,,1065,852,,905.25,85,,,percent of total billed charges,85% of total billed charges,29.21,100,,,fee schedule,Pays 100% Medicare OPPS,29.21,100,,,fee schedule,Pays 100% Medicare OPPS,29.21,100,,,fee schedule,Pays 100% Medicare OPPS,37.97,130,,,fee schedule,Pays 130% Medicare OPPS,27.25,120.37,,,fee schedule,120.37% of custom fee schedule,601.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,601.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,601.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,601.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,29.79,102,,,fee schedule,Pays 102% Medicare OPPS,958.5,90,,,percent of total billed charges,90% of total billed charges,28.34,125.18,,,fee schedule,125.18% of custom fee schedule,731.66,68.7,,,percent of total billed charges,68.7% of total billed charges,852,80,,,percent of total billed charges,80 percent of total billed charges,29.21,100,,,fee schedule,Pays 100% Medicare OPPS,26.28,90,,,fee schedule,Pays 90% Medicare OPPS,617.7,58,,,percent of total billed charges,58% of total billed charges,27.25,120.37,,,fee schedule,120.37% of custom fee schedule,29.21,100,,,fee schedule,Pays 100% Medicare OPPS,37.97,130,,,fee schedule,Pays 130% Medicare OPPS,905.25,85,,,percent of total billed charges,85% of total billed charges,29.21,100,,,fee schedule,Pays 100% Medicare OPPS,26.28,958.5,
YO ANTIBODIES,3000337,CDM,301,RC,84182,HCPCS,Outpatient,,,1065,852,,905.25,85,,,percent of total billed charges,85% of total billed charges,29.21,100,,,fee schedule,Pays 100% Medicare OPPS,29.21,100,,,fee schedule,Pays 100% Medicare OPPS,29.21,100,,,fee schedule,Pays 100% Medicare OPPS,37.97,130,APC,,fee schedule,Pays 130% Medicare OPPS,27.25,120.37,,,fee schedule,120.37% of custom fee schedule,601.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,601.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,601.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,601.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,29.79,102,,,fee schedule,Pays 102% Medicare OPPS,958.5,90,,,percent of total billed charges,90% of total billed charges,28.34,125.18,,,fee schedule,125.18% of custom fee schedule,731.66,68.7,,,percent of total billed charges,68.7% of total billed charges,852,80,,,percent of total billed charges,80 percent of total billed charges,29.21,100,,,fee schedule,Pays 100% Medicare OPPS,26.28,90,,,fee schedule,Pays 90% Medicare OPPS,617.7,58,,,percent of total billed charges,58% of total billed charges,27.25,120.37,,,fee schedule,120.37% of custom fee schedule,29.21,100,,,fee schedule,Pays 100% Medicare OPPS,37.97,130,APC,,fee schedule,Pays 130% Medicare OPPS,905.25,85,,,percent of total billed charges,85% of total billed charges,29.21,100,,,fee schedule,Pays 100% Medicare OPPS,26.28,958.5,
Study of vessels on both sides of the head and neck,4693880,CDM,921,RC,93880,HCPCS,Outpatient,,,1065,852,,905.25,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,216.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,601.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,601.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,601.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,601.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,958.5,90,,,percent of total billed charges,90% of total billed charges,372.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,731.66,68.7,,,percent of total billed charges,68.7% of total billed charges,852,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,617.7,58,,,percent of total billed charges,58% of total billed charges,216.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,905.25,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,958.5,
ENDOPATH ETS CUTTER,7950186,CDM,270,RC,,,Outpatient,,,1065,852,,905.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,216.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,601.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,601.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,601.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,601.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,958.5,90,,,percent of total billed charges,90% of total billed charges,372.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,731.66,68.7,,,percent of total billed charges,68.7% of total billed charges,852,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,617.7,58,,,percent of total billed charges,58% of total billed charges,216.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,905.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,216.94,958.5,
SCREW BONE 2.0 X 14MM CHARLOTTE SNAP-OFF,1570030,CDM,278,RC,C1713,HCPCS,Both,,,1070,856,,909.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,217.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,963,90,,,percent of total billed charges,90% of total billed charges,374.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,735.09,68.7,,,percent of total billed charges,68.7% of total billed charges,856,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,620.6,58,,,percent of total billed charges,58% of total billed charges,217.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,909.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,963,
LEXISCAN .4MG/5ML SYRINGE,2600157,CDM,636,RC,J2785,HCPCS,Both,,,1070,856,,909.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,73.85,120.37,,,fee schedule,120.37% of custom fee schedule,558.23,52.17,,,case rate,100% of BCBS case rate,558.23,52.17,,,case rate,100% of BCBS case rate,558.23,52.17,,,case rate,100% of BCBS case rate,558.23,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,963,90,,,percent of total billed charges,90% of total billed charges,76.8,125.18,,,fee schedule,125.18% of custom fee schedule,735.09,68.7,,,percent of total billed charges,68.7% of total billed charges,856,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,620.6,58,,,percent of total billed charges,58% of total billed charges,73.85,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,909.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,73.85,963,
3RD IA-2 ANTIBODY,3086342,CDM,301,RC,86341,HCPCS,Outpatient,,,1075,860,,913.75,85,,,percent of total billed charges,85% of total billed charges,23.57,100,,,fee schedule,Pays 100% Medicare OPPS,23.57,100,,,fee schedule,Pays 100% Medicare OPPS,23.57,100,,,fee schedule,Pays 100% Medicare OPPS,30.64,130,,,fee schedule,Pays 130% Medicare OPPS,29.96,120.37,,,fee schedule,120.37% of custom fee schedule,607.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,607.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,607.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,607.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,24.04,102,,,fee schedule,Pays 102% Medicare OPPS,967.5,90,,,percent of total billed charges,90% of total billed charges,31.16,125.18,,,fee schedule,125.18% of custom fee schedule,738.53,68.7,,,percent of total billed charges,68.7% of total billed charges,860,80,,,percent of total billed charges,80 percent of total billed charges,23.57,100,,,fee schedule,Pays 100% Medicare OPPS,21.21,90,,,fee schedule,Pays 90% Medicare OPPS,623.5,58,,,percent of total billed charges,58% of total billed charges,29.96,120.37,,,fee schedule,120.37% of custom fee schedule,23.57,100,,,fee schedule,Pays 100% Medicare OPPS,30.64,130,,,fee schedule,Pays 130% Medicare OPPS,913.75,85,,,percent of total billed charges,85% of total billed charges,23.57,100,,,fee schedule,Pays 100% Medicare OPPS,21.21,967.5,
STAPLER CURVED INTRALUMINAL ECS25A,7950288,CDM,272,RC,,,Outpatient,,,1075,860,,913.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,218.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,607.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,607.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,607.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,607.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,967.5,90,,,percent of total billed charges,90% of total billed charges,376.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,738.53,68.7,,,percent of total billed charges,68.7% of total billed charges,860,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,623.5,58,,,percent of total billed charges,58% of total billed charges,218.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,913.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,218.98,967.5,
STAPLER CURVED INTRALUMINAL ECS29A,7950289,CDM,272,RC,,,Outpatient,,,1075,860,,913.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,218.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,607.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,607.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,607.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,607.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,967.5,90,,,percent of total billed charges,90% of total billed charges,376.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,738.53,68.7,,,percent of total billed charges,68.7% of total billed charges,860,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,623.5,58,,,percent of total billed charges,58% of total billed charges,218.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,913.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,218.98,967.5,
STAPLER CURVED INTRALUMINAL ECS25B,7950321,CDM,272,RC,,,Outpatient,,,1075,860,,913.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,218.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,607.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,607.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,607.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,607.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,967.5,90,,,percent of total billed charges,90% of total billed charges,376.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,738.53,68.7,,,percent of total billed charges,68.7% of total billed charges,860,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,623.5,58,,,percent of total billed charges,58% of total billed charges,218.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,913.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,218.98,967.5,
SCREWS LAG ALL/SIZES,7901055,CDM,278,RC,,,Both,,,1085,868,,922.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,221.01,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,976.5,90,,,percent of total billed charges,90% of total billed charges,379.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,745.4,68.7,,,percent of total billed charges,68.7% of total billed charges,868,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,629.3,58,,,percent of total billed charges,58% of total billed charges,221.01,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,922.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,976.5,
HEMORRHOID EXTERNAL,2046083,CDM,450,RC,,,Outpatient,,,1090,872,,926.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,222.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,615.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,615.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,615.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,615.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,981,90,,,percent of total billed charges,90% of total billed charges,381.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,748.83,68.7,,,percent of total billed charges,68.7% of total billed charges,872,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,632.2,58,,,percent of total billed charges,58% of total billed charges,222.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,926.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,222.03,981,
"3RD AMINO ACID PROFILE,URINE",3000109,CDM,301,RC,82128,HCPCS,Outpatient,,,1090,872,,926.5,85,,,percent of total billed charges,85% of total billed charges,13.87,100,,,fee schedule,Pays 100% Medicare OPPS,13.87,100,,,fee schedule,Pays 100% Medicare OPPS,13.87,100,,,fee schedule,Pays 100% Medicare OPPS,18.03,130,,,fee schedule,Pays 130% Medicare OPPS,20.98,120.37,,,fee schedule,120.37% of custom fee schedule,615.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,615.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,615.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,615.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.14,102,,,fee schedule,Pays 102% Medicare OPPS,981,90,,,percent of total billed charges,90% of total billed charges,21.82,125.18,,,fee schedule,125.18% of custom fee schedule,748.83,68.7,,,percent of total billed charges,68.7% of total billed charges,872,80,,,percent of total billed charges,80 percent of total billed charges,13.87,100,,,fee schedule,Pays 100% Medicare OPPS,12.48,90,,,fee schedule,Pays 90% Medicare OPPS,632.2,58,,,percent of total billed charges,58% of total billed charges,20.98,120.37,,,fee schedule,120.37% of custom fee schedule,13.87,100,,,fee schedule,Pays 100% Medicare OPPS,18.03,130,,,fee schedule,Pays 130% Medicare OPPS,926.5,85,,,percent of total billed charges,85% of total billed charges,13.87,100,,,fee schedule,Pays 100% Medicare OPPS,12.48,981,
"3RD AMINO ACID PROFILE,PLASMA",3082128,CDM,301,RC,82128,HCPCS,Outpatient,,,1090,872,,926.5,85,,,percent of total billed charges,85% of total billed charges,13.87,100,,,fee schedule,Pays 100% Medicare OPPS,13.87,100,,,fee schedule,Pays 100% Medicare OPPS,13.87,100,,,fee schedule,Pays 100% Medicare OPPS,18.03,130,,,fee schedule,Pays 130% Medicare OPPS,20.98,120.37,,,fee schedule,120.37% of custom fee schedule,615.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,615.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,615.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,615.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,14.14,102,,,fee schedule,Pays 102% Medicare OPPS,981,90,,,percent of total billed charges,90% of total billed charges,21.82,125.18,,,fee schedule,125.18% of custom fee schedule,748.83,68.7,,,percent of total billed charges,68.7% of total billed charges,872,80,,,percent of total billed charges,80 percent of total billed charges,13.87,100,,,fee schedule,Pays 100% Medicare OPPS,12.48,90,,,fee schedule,Pays 90% Medicare OPPS,632.2,58,,,percent of total billed charges,58% of total billed charges,20.98,120.37,,,fee schedule,120.37% of custom fee schedule,13.87,100,,,fee schedule,Pays 100% Medicare OPPS,18.03,130,,,fee schedule,Pays 130% Medicare OPPS,926.5,85,,,percent of total billed charges,85% of total billed charges,13.87,100,,,fee schedule,Pays 100% Medicare OPPS,12.48,981,
"ORGANIC ACID PROFIL,URINE",3083918,CDM,301,RC,83918,HCPCS,Outpatient,,,1090,872,,926.5,85,,,percent of total billed charges,85% of total billed charges,23.6,100,,,fee schedule,Pays 100% Medicare OPPS,23.6,100,,,fee schedule,Pays 100% Medicare OPPS,23.6,100,,,fee schedule,Pays 100% Medicare OPPS,30.68,130,APC,,fee schedule,Pays 130% Medicare OPPS,24.92,120.37,,,fee schedule,120.37% of custom fee schedule,615.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,615.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,615.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,615.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,24.07,102,,,fee schedule,Pays 102% Medicare OPPS,981,90,,,percent of total billed charges,90% of total billed charges,25.91,125.18,,,fee schedule,125.18% of custom fee schedule,748.83,68.7,,,percent of total billed charges,68.7% of total billed charges,872,80,,,percent of total billed charges,80 percent of total billed charges,23.6,100,,,fee schedule,Pays 100% Medicare OPPS,21.24,90,,,fee schedule,Pays 90% Medicare OPPS,632.2,58,,,percent of total billed charges,58% of total billed charges,24.92,120.37,,,fee schedule,120.37% of custom fee schedule,23.6,100,,,fee schedule,Pays 100% Medicare OPPS,30.68,130,APC,,fee schedule,Pays 130% Medicare OPPS,926.5,85,,,percent of total billed charges,85% of total billed charges,23.6,100,,,fee schedule,Pays 100% Medicare OPPS,21.24,981,
XR BONE SURVEY-COMPLETE,4076062,CDM,320,RC,77075,HCPCS,Outpatient,,,1090,872,,926.5,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,222.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,615.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,615.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,615.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,612.58,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,981,90,,,percent of total billed charges,90% of total billed charges,381.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,748.83,68.7,,,percent of total billed charges,68.7% of total billed charges,872,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,632.2,58,,,percent of total billed charges,58% of total billed charges,222.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,926.5,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,981,
PORT-A-CATH 21-4000-24,7905965,CDM,278,RC,C1751,HCPCS,Both,,,1095,876,,930.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,223.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,0.01,,,,case rate,Not reimbursable per contract,,,,,other,Not reimbursable per contract,985.5,90,,,percent of total billed charges,90% of total billed charges,383.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,752.27,68.7,,,percent of total billed charges,68.7% of total billed charges,876,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,635.1,58,,,percent of total billed charges,58% of total billed charges,223.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,930.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.01,985.5,
CARDIOVERSION,1092960,CDM,450,RC,92960,HCPCS,Outpatient,,,1100,880,,935,85,,,percent of total billed charges,85% of total billed charges,504.64,100,,,fee schedule,Pays 100% Medicare OPPS,504.64,100,,,fee schedule,Pays 100% Medicare OPPS,504.64,100,,,fee schedule,Pays 100% Medicare OPPS,672.51,130,,,fee schedule,Pays 130% Medicare OPPS,224.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,621.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,621.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,621.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,621.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,514.73,102,,,fee schedule,Pays 102% Medicare OPPS,990,90,,,percent of total billed charges,90% of total billed charges,385,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,755.7,68.7,,,percent of total billed charges,68.7% of total billed charges,880,80,,,percent of total billed charges,80 percent of total billed charges,504.64,100,,,fee schedule,Pays 100% Medicare OPPS,454.17,90,,,fee schedule,Pays 90% Medicare OPPS,638,58,,,percent of total billed charges,58% of total billed charges,224.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,517.3,100,,,fee schedule,Pays 100% Medicare OPPS,672.51,130,,,fee schedule,Pays 130% Medicare OPPS,935,85,,,percent of total billed charges,85% of total billed charges,504.64,100,,,fee schedule,Pays 100% Medicare OPPS,224.07,990,
EXTERNAL PACEMAKER,2092953,CDM,480,RC,92953,HCPCS,Outpatient,,,1100,880,,935,85,,,percent of total billed charges,85% of total billed charges,504.64,100,,,fee schedule,Pays 100% Medicare OPPS,504.64,100,,,fee schedule,Pays 100% Medicare OPPS,504.64,100,,,fee schedule,Pays 100% Medicare OPPS,672.51,130,,,fee schedule,Pays 130% Medicare OPPS,224.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,514.73,102,,,fee schedule,Pays 102% Medicare OPPS,990,90,,,percent of total billed charges,90% of total billed charges,385,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,755.7,68.7,,,percent of total billed charges,68.7% of total billed charges,880,80,,,percent of total billed charges,80 percent of total billed charges,504.64,100,,,fee schedule,Pays 100% Medicare OPPS,454.17,90,,,fee schedule,Pays 90% Medicare OPPS,638,58,,,percent of total billed charges,58% of total billed charges,224.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,517.3,100,,,fee schedule,Pays 100% Medicare OPPS,672.51,130,,,fee schedule,Pays 130% Medicare OPPS,935,85,,,percent of total billed charges,85% of total billed charges,504.64,100,,,fee schedule,Pays 100% Medicare OPPS,224.07,990,
CARDIOVERSION ER,2092960,CDM,450,RC,92960,HCPCS,Outpatient,,,1100,880,,935,85,,,percent of total billed charges,85% of total billed charges,504.64,100,,,fee schedule,Pays 100% Medicare OPPS,504.64,100,,,fee schedule,Pays 100% Medicare OPPS,504.64,100,,,fee schedule,Pays 100% Medicare OPPS,672.51,130,,,fee schedule,Pays 130% Medicare OPPS,224.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,621.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,621.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,621.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,621.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,514.73,102,,,fee schedule,Pays 102% Medicare OPPS,990,90,,,percent of total billed charges,90% of total billed charges,385,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,755.7,68.7,,,percent of total billed charges,68.7% of total billed charges,880,80,,,percent of total billed charges,80 percent of total billed charges,504.64,100,,,fee schedule,Pays 100% Medicare OPPS,454.17,90,,,fee schedule,Pays 90% Medicare OPPS,638,58,,,percent of total billed charges,58% of total billed charges,224.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,517.3,100,,,fee schedule,Pays 100% Medicare OPPS,672.51,130,,,fee schedule,Pays 130% Medicare OPPS,935,85,,,percent of total billed charges,85% of total billed charges,504.64,100,,,fee schedule,Pays 100% Medicare OPPS,224.07,990,
"Emergency department visit, problem of high severity",2099284,CDM,450,RC,99284,HCPCS,Outpatient,,,1100,880,,935,85,,,percent of total billed charges,85% of total billed charges,326.77,100,,,fee schedule,Pays 100% Medicare OPPS,326.77,100,,,fee schedule,Pays 100% Medicare OPPS,326.77,100,,,fee schedule,Pays 100% Medicare OPPS,436.35,130,,,fee schedule,Pays 130% Medicare OPPS,224.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1100,100,,,percent of total billed charges,671 dollar flat fee for ER,1100,100,,,percent of total billed charges,671 dollar flat fee for ER,1100,100,,,percent of total billed charges,671 dollar flat fee for ER,1100,100,,,percent of total billed charges,671 dollar flat fee for ER,333.31,102,,,fee schedule,Pays 102% Medicare OPPS,990,90,,,percent of total billed charges,90% of total billed charges,385,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,755.7,68.7,,,percent of total billed charges,68.7% of total billed charges,880,80,,,percent of total billed charges,80 percent of total billed charges,326.77,100,,,fee schedule,Pays 100% Medicare OPPS,294.08,90,,,fee schedule,Pays 90% Medicare OPPS,638,58,,,percent of total billed charges,58% of total billed charges,224.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,335.65,100,,,fee schedule,Pays 100% Medicare OPPS,436.35,130,,,fee schedule,Pays 130% Medicare OPPS,935,85,,,percent of total billed charges,85% of total billed charges,326.77,100,,,fee schedule,Pays 100% Medicare OPPS,224.07,1100,
........NM HIDA WITH EJECTION FRACTION,4578223,CDM,341,RC,78227,HCPCS,Outpatient,,,1100,880,,935,85,,,percent of total billed charges,85% of total billed charges,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,576.87,130,,,fee schedule,Pays 130% Medicare OPPS,224.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,621.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,621.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,621.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,621.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,448.38,102,,,fee schedule,Pays 102% Medicare OPPS,990,90,,,percent of total billed charges,90% of total billed charges,385,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,755.7,68.7,,,percent of total billed charges,68.7% of total billed charges,880,80,,,percent of total billed charges,80 percent of total billed charges,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,395.63,90,,,fee schedule,Pays 90% Medicare OPPS,638,58,,,percent of total billed charges,58% of total billed charges,224.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,443.74,100,,,fee schedule,Pays 100% Medicare OPPS,576.87,130,,,fee schedule,Pays 130% Medicare OPPS,935,85,,,percent of total billed charges,85% of total billed charges,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,224.07,990,
NM HIDA W/O EJECTION FRACTION,4578226,CDM,341,RC,78226,HCPCS,Outpatient,,,1100,880,,935,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,224.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,621.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,621.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,621.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,621.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,345.39,102,,,fee schedule,Pays 102% Medicare OPPS,990,90,,,percent of total billed charges,90% of total billed charges,385,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,755.7,68.7,,,percent of total billed charges,68.7% of total billed charges,880,80,,,percent of total billed charges,80 percent of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,304.76,90,,,fee schedule,Pays 90% Medicare OPPS,638,58,,,percent of total billed charges,58% of total billed charges,224.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,341.87,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,935,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,224.07,990,
NM HIDA WITH EJECTION FRACTION,4578227,CDM,341,RC,78227,HCPCS,Outpatient,,,1100,880,,935,85,,,percent of total billed charges,85% of total billed charges,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,576.87,130,,,fee schedule,Pays 130% Medicare OPPS,224.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,621.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,621.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,621.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,621.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,448.38,102,,,fee schedule,Pays 102% Medicare OPPS,990,90,,,percent of total billed charges,90% of total billed charges,385,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,755.7,68.7,,,percent of total billed charges,68.7% of total billed charges,880,80,,,percent of total billed charges,80 percent of total billed charges,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,395.63,90,,,fee schedule,Pays 90% Medicare OPPS,638,58,,,percent of total billed charges,58% of total billed charges,224.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,443.74,100,,,fee schedule,Pays 100% Medicare OPPS,576.87,130,,,fee schedule,Pays 130% Medicare OPPS,935,85,,,percent of total billed charges,85% of total billed charges,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,224.07,990,
NM PULMONARY PERFUSION,4578580,CDM,341,RC,78580,HCPCS,Outpatient,,,1110,888,,943.5,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,226.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,627.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,627.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,627.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,627.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,345.39,102,,,fee schedule,Pays 102% Medicare OPPS,999,90,,,percent of total billed charges,90% of total billed charges,388.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,762.57,68.7,,,percent of total billed charges,68.7% of total billed charges,888,80,,,percent of total billed charges,80 percent of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,304.76,90,,,fee schedule,Pays 90% Medicare OPPS,643.8,58,,,percent of total billed charges,58% of total billed charges,226.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,341.87,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,943.5,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,226.11,999,
REM FB EXT EYE,2065220,CDM,450,RC,65220,HCPCS,Outpatient,,,1120,896,,952,85,,,percent of total billed charges,85% of total billed charges,243.8,100,,,fee schedule,Pays 100% Medicare OPPS,243.8,100,,,fee schedule,Pays 100% Medicare OPPS,243.8,100,,,fee schedule,Pays 100% Medicare OPPS,431.73,130,,,fee schedule,Pays 130% Medicare OPPS,228.14,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,632.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,632.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,632.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,632.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,248.67,102,,,fee schedule,Pays 102% Medicare OPPS,1008,90,,,percent of total billed charges,90% of total billed charges,392,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,769.44,68.7,,,percent of total billed charges,68.7% of total billed charges,896,80,,,percent of total billed charges,80 percent of total billed charges,243.8,100,,,fee schedule,Pays 100% Medicare OPPS,219.42,90,,,fee schedule,Pays 90% Medicare OPPS,649.6,58,,,percent of total billed charges,58% of total billed charges,228.14,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,332.1,100,,,fee schedule,Pays 100% Medicare OPPS,431.73,130,,,fee schedule,Pays 130% Medicare OPPS,952,85,,,percent of total billed charges,85% of total billed charges,243.8,100,,,fee schedule,Pays 100% Medicare OPPS,219.42,1008,
3RD HEPATITIS DELTA VIRSUS AB,3086692,CDM,302,RC,87799,HCPCS,Outpatient,,,1120,896,,952,85,,,percent of total billed charges,85% of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,130,APC,,fee schedule,Pays 130% Medicare OPPS,228.14,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,632.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,632.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,632.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,632.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,43.69,102,,,fee schedule,Pays 102% Medicare OPPS,1008,90,,,percent of total billed charges,90% of total billed charges,392,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,769.44,68.7,,,percent of total billed charges,68.7% of total billed charges,896,80,,,percent of total billed charges,80 percent of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,38.55,90,,,fee schedule,Pays 90% Medicare OPPS,649.6,58,,,percent of total billed charges,58% of total billed charges,228.14,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,130,APC,,fee schedule,Pays 130% Medicare OPPS,952,85,,,percent of total billed charges,85% of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,38.55,1008,
XR GI / AC,4007424,CDM,320,RC,74246,HCPCS,Outpatient,,,1125,900,,956.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.21,130,,,fee schedule,Pays 130% Medicare OPPS,229.16,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,635.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,635.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,635.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,632.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.67,102,,,fee schedule,Pays 102% Medicare OPPS,1012.5,90,,,percent of total billed charges,90% of total billed charges,393.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,772.88,68.7,,,percent of total billed charges,68.7% of total billed charges,900,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,652.5,58,,,percent of total billed charges,58% of total billed charges,229.16,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.21,130,,,fee schedule,Pays 130% Medicare OPPS,956.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,1012.5,
XR GI SINGLE CONTRAST,4074240,CDM,320,RC,74240,HCPCS,Outpatient,,,1125,900,,956.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.21,130,,,fee schedule,Pays 130% Medicare OPPS,229.16,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,635.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,635.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,635.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,632.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.67,102,,,fee schedule,Pays 102% Medicare OPPS,1012.5,90,,,percent of total billed charges,90% of total billed charges,393.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,772.88,68.7,,,percent of total billed charges,68.7% of total billed charges,900,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,652.5,58,,,percent of total billed charges,58% of total billed charges,229.16,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.21,130,,,fee schedule,Pays 130% Medicare OPPS,956.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,1012.5,
XR GI W/SB SINGLE CONTRAST,4074245,CDM,320,RC,74245,HCPCS,Outpatient,,,1125,900,,956.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,229.16,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,635.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,635.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,635.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,632.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1012.5,90,,,percent of total billed charges,90% of total billed charges,393.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,772.88,68.7,,,percent of total billed charges,68.7% of total billed charges,900,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,652.5,58,,,percent of total billed charges,58% of total billed charges,229.16,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,956.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,229.16,1012.5,
XR GI/AC W/SB,4074249,CDM,320,RC,74249,HCPCS,Outpatient,,,1125,900,,956.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,229.16,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,635.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,635.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,635.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,632.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1012.5,90,,,percent of total billed charges,90% of total billed charges,393.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,772.88,68.7,,,percent of total billed charges,68.7% of total billed charges,900,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,652.5,58,,,percent of total billed charges,58% of total billed charges,229.16,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,956.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,229.16,1012.5,
CAPSULAR TENSION RING,7905137,CDM,272,RC,,,Outpatient,,,1125,900,,956.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,229.16,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,635.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,635.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,635.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,635.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1012.5,90,,,percent of total billed charges,90% of total billed charges,393.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,772.88,68.7,,,percent of total billed charges,68.7% of total billed charges,900,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,652.5,58,,,percent of total billed charges,58% of total billed charges,229.16,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,956.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,229.16,1012.5,
US GUIDE THORA/PARACENTIS,4600010,CDM,402,RC,76942,HCPCS,Outpatient,,,1135,908,,964.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,231.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,641.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,641.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,641.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,637.87,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1021.5,90,,,percent of total billed charges,90% of total billed charges,397.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,779.75,68.7,,,percent of total billed charges,68.7% of total billed charges,908,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,658.3,58,,,percent of total billed charges,58% of total billed charges,231.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,964.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,231.2,1021.5,
TRACHEOSTOMY KIT PERCUTANEOUS DILATION,7905593,CDM,272,RC,,,Outpatient,,,1140,912,,969,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,232.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,644.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,644.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,644.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,644.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1026,90,,,percent of total billed charges,90% of total billed charges,399,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,783.18,68.7,,,percent of total billed charges,68.7% of total billed charges,912,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,661.2,58,,,percent of total billed charges,58% of total billed charges,232.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,969,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,232.22,1026,
BOTULINUM TOXIN A AB,3000033,CDM,300,RC,84182,HCPCS,Outpatient,,,1145,916,,973.25,85,,,percent of total billed charges,85% of total billed charges,29.21,100,,,fee schedule,Pays 100% Medicare OPPS,29.21,100,,,fee schedule,Pays 100% Medicare OPPS,29.21,100,,,fee schedule,Pays 100% Medicare OPPS,37.97,130,,,fee schedule,Pays 130% Medicare OPPS,27.25,120.37,,,fee schedule,120.37% of custom fee schedule,646.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,646.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,646.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,646.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,29.79,102,,,fee schedule,Pays 102% Medicare OPPS,1030.5,90,,,percent of total billed charges,90% of total billed charges,28.34,125.18,,,fee schedule,125.18% of custom fee schedule,786.62,68.7,,,percent of total billed charges,68.7% of total billed charges,916,80,,,percent of total billed charges,80 percent of total billed charges,29.21,100,,,fee schedule,Pays 100% Medicare OPPS,26.28,90,,,fee schedule,Pays 90% Medicare OPPS,664.1,58,,,percent of total billed charges,58% of total billed charges,27.25,120.37,,,fee schedule,120.37% of custom fee schedule,29.21,100,,,fee schedule,Pays 100% Medicare OPPS,37.97,130,,,fee schedule,Pays 130% Medicare OPPS,973.25,85,,,percent of total billed charges,85% of total billed charges,29.21,100,,,fee schedule,Pays 100% Medicare OPPS,26.28,1030.5,
ENTEROVIRUS PCR,3087798,CDM,300,RC,87498,HCPCS,Outpatient,,,1145,916,,973.25,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,APC,,fee schedule,Pays 130% Medicare OPPS,29.7,120.37,,,fee schedule,120.37% of custom fee schedule,646.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,646.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,646.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,646.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,35.79,102,,,fee schedule,Pays 102% Medicare OPPS,1030.5,90,,,percent of total billed charges,90% of total billed charges,30.88,125.18,,,fee schedule,125.18% of custom fee schedule,786.62,68.7,,,percent of total billed charges,68.7% of total billed charges,916,80,,,percent of total billed charges,80 percent of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,31.58,90,,,fee schedule,Pays 90% Medicare OPPS,664.1,58,,,percent of total billed charges,58% of total billed charges,29.7,120.37,,,fee schedule,120.37% of custom fee schedule,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,45.61,130,APC,,fee schedule,Pays 130% Medicare OPPS,973.25,85,,,percent of total billed charges,85% of total billed charges,35.09,100,,,fee schedule,Pays 100% Medicare OPPS,29.7,1030.5,
Evaluation through measurement of fetal nuchal translucency,4676813,CDM,402,RC,76813,HCPCS,Outpatient,,,1145,916,,973.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,233.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,646.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,646.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,646.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,643.49,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,1030.5,90,,,percent of total billed charges,90% of total billed charges,400.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,786.62,68.7,,,percent of total billed charges,68.7% of total billed charges,916,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,664.1,58,,,percent of total billed charges,58% of total billed charges,233.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,973.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,1030.5,
NM LTD AREA BONE SCAN,4578300,CDM,341,RC,78300,HCPCS,Outpatient,,,1150,920,,977.5,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,234.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,649.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,649.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,649.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,649.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,345.39,102,,,fee schedule,Pays 102% Medicare OPPS,1035,90,,,percent of total billed charges,90% of total billed charges,402.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,790.05,68.7,,,percent of total billed charges,68.7% of total billed charges,920,80,,,percent of total billed charges,80 percent of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,304.76,90,,,fee schedule,Pays 90% Medicare OPPS,667,58,,,percent of total billed charges,58% of total billed charges,234.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,341.87,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,977.5,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,234.26,1035,
Ultrasound of abdomen with all areas scanned,4676700,CDM,402,RC,76700,HCPCS,Outpatient,,,1150,920,,977.5,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,234.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,649.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,649.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,649.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,646.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,1035,90,,,percent of total billed charges,90% of total billed charges,402.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,790.05,68.7,,,percent of total billed charges,68.7% of total billed charges,920,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,667,58,,,percent of total billed charges,58% of total billed charges,234.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,977.5,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,1035,
NM THYROID IMAGING ONLY,4578010,CDM,341,RC,78013,HCPCS,Outpatient,,,1165,932,,990.25,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,237.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,658.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,658.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,658.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,658.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,345.39,102,,,fee schedule,Pays 102% Medicare OPPS,1048.5,90,,,percent of total billed charges,90% of total billed charges,407.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,800.36,68.7,,,percent of total billed charges,68.7% of total billed charges,932,80,,,percent of total billed charges,80 percent of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,304.76,90,,,fee schedule,Pays 90% Medicare OPPS,675.7,58,,,percent of total billed charges,58% of total billed charges,237.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,341.87,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,990.25,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,237.31,1048.5,
"EPOGEN/PROCRIT (EPOETIN) INJ 10,000UNITS",2601280,CDM,636,RC,J0886,HCPCS,Both,,,1170,936,,994.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,238.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,610.4,52.17,,,case rate,100% of BCBS case rate,610.4,52.17,,,case rate,100% of BCBS case rate,610.4,52.17,,,case rate,100% of BCBS case rate,610.4,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1053,90,,,percent of total billed charges,90% of total billed charges,409.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,803.79,68.7,,,percent of total billed charges,68.7% of total billed charges,936,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,678.6,58,,,percent of total billed charges,58% of total billed charges,238.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,994.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,238.33,1053,
NEUPOGEN (FILGRASTIM) INJ 300MCG,2601391,CDM,636,RC,J1440,HCPCS,Both,,,1175,940,,998.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,81.14,130,APC,,fee schedule,Pays 130% Medicare OPPS,239.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,613.01,52.17,,,case rate,100% of BCBS case rate,613.01,52.17,,,case rate,100% of BCBS case rate,613.01,52.17,,,case rate,100% of BCBS case rate,613.01,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1057.5,90,,,percent of total billed charges,90% of total billed charges,411.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,807.23,68.7,,,percent of total billed charges,68.7% of total billed charges,940,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,681.5,58,,,percent of total billed charges,58% of total billed charges,239.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,62.42,100,,,fee schedule,Pays 100% Medicare OPPS,81.14,130,APC,,fee schedule,Pays 130% Medicare OPPS,998.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,62.42,1057.5,
RC BLOOD L/R IRRADIATED,3109038,CDM,390,RC,P9040,HCPCS,Outpatient,,,1175,940,,998.75,85,,,percent of total billed charges,85% of total billed charges,266.02,100,,,fee schedule,Pays 100% Medicare OPPS,266.02,100,,,fee schedule,Pays 100% Medicare OPPS,266.02,100,,,fee schedule,Pays 100% Medicare OPPS,336.85,130,,,fee schedule,Pays 130% Medicare OPPS,239.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,663.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,663.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,663.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,663.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,271.35,102,,,fee schedule,Pays 102% Medicare OPPS,1057.5,90,,,percent of total billed charges,90% of total billed charges,411.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,807.23,68.7,,,percent of total billed charges,68.7% of total billed charges,940,80,,,percent of total billed charges,80 percent of total billed charges,266.02,100,,,fee schedule,Pays 100% Medicare OPPS,239.42,90,,,fee schedule,Pays 90% Medicare OPPS,681.5,58,,,percent of total billed charges,58% of total billed charges,239.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,259.12,100,,,fee schedule,Pays 100% Medicare OPPS,336.85,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,266.02,100,,,fee schedule,Pays 100% Medicare OPPS,239.35,1057.5,
TROCAR BLUNT TIP OMST12BT,7950121,CDM,270,RC,,,Outpatient,,,1175,940,,998.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,239.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,663.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,663.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,663.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,663.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1057.5,90,,,percent of total billed charges,90% of total billed charges,411.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,807.23,68.7,,,percent of total billed charges,68.7% of total billed charges,940,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,681.5,58,,,percent of total billed charges,58% of total billed charges,239.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,998.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,239.35,1057.5,
REMOVE MESH FROM ABD WALL,1511008,CDM,360,RC,11008,HCPCS,Outpatient,,,1190,952,,1011.5,85,,,percent of total billed charges,85% of total billed charges,1190,100,,,fee schedule,Pays 100% Medicare OPPS,1190,100,,,fee schedule,Pays 100% Medicare OPPS,1190,100,,,fee schedule,Pays 100% Medicare OPPS,1190,130,,,fee schedule,Pays 130% Medicare OPPS,242.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,1190,102,,,fee schedule,Pays 102% Medicare OPPS,1071,90,,,percent of total billed charges,90% of total billed charges,416.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,817.53,68.7,,,percent of total billed charges,68.7% of total billed charges,952,80,,,percent of total billed charges,80 percent of total billed charges,1190,100,,,fee schedule,Pays 100% Medicare OPPS,1190,90,,,fee schedule,Pays 90% Medicare OPPS,690.2,58,,,percent of total billed charges,58% of total billed charges,242.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1190,100,,,fee schedule,Pays 100% Medicare OPPS,1190,130,,,fee schedule,Pays 130% Medicare OPPS,1011.5,85,,,percent of total billed charges,85% of total billed charges,1190,100,,,fee schedule,Pays 100% Medicare OPPS,242.4,1190,
BAMLANIVIMAB POST ADMIN MONITORING,2610239,CDM,771,RC,M0239,HCPCS,Outpatient,,,1190,952,,1011.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,242.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,672.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,672.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,672.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,672.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1071,90,,,percent of total billed charges,90% of total billed charges,416.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,817.53,68.7,,,percent of total billed charges,68.7% of total billed charges,952,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,690.2,58,,,percent of total billed charges,58% of total billed charges,242.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,242.4,1071,
INJ CORPORA CAVERNOSA,2054235,CDM,450,RC,54235,HCPCS,Outpatient,,,1195,956,,1015.75,85,,,percent of total billed charges,85% of total billed charges,239.04,100,,,fee schedule,Pays 100% Medicare OPPS,239.04,100,,,fee schedule,Pays 100% Medicare OPPS,239.04,100,,,fee schedule,Pays 100% Medicare OPPS,245.69,130,,,fee schedule,Pays 130% Medicare OPPS,243.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,675.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,675.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,675.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,675.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,243.81,102,,,fee schedule,Pays 102% Medicare OPPS,1075.5,90,,,percent of total billed charges,90% of total billed charges,418.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,820.97,68.7,,,percent of total billed charges,68.7% of total billed charges,956,80,,,percent of total billed charges,80 percent of total billed charges,239.04,100,,,fee schedule,Pays 100% Medicare OPPS,215.13,90,,,fee schedule,Pays 90% Medicare OPPS,693.1,58,,,percent of total billed charges,58% of total billed charges,243.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,188.99,100,,,fee schedule,Pays 100% Medicare OPPS,245.69,130,,,fee schedule,Pays 130% Medicare OPPS,1015.75,85,,,percent of total billed charges,85% of total billed charges,239.04,100,,,fee schedule,Pays 100% Medicare OPPS,188.99,1075.5,
XR FLURO GUIDANCE NEEDLE PLACEMENT,4076000,CDM,320,RC,77002,HCPCS,Outpatient,,,1195,956,,1015.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,243.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,675.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,675.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,675.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,671.59,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1075.5,90,,,percent of total billed charges,90% of total billed charges,418.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,820.97,68.7,,,percent of total billed charges,68.7% of total billed charges,956,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,693.1,58,,,percent of total billed charges,58% of total billed charges,243.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1015.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,243.42,1075.5,
US GUIDANCE-NEEDLE BIOPS,4600008,CDM,402,RC,76942,HCPCS,Outpatient,,,1195,956,,1015.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,243.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,675.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,675.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,675.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,671.59,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1075.5,90,,,percent of total billed charges,90% of total billed charges,418.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,820.97,68.7,,,percent of total billed charges,68.7% of total billed charges,956,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,693.1,58,,,percent of total billed charges,58% of total billed charges,243.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1015.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,243.42,1075.5,
US VASCULAR-AORTA-IVC-ILIAC-COMPLETE,4600023,CDM,921,RC,93978,HCPCS,Outpatient,,,1195,956,,1015.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,243.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,675.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,675.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,675.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,675.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,1075.5,90,,,percent of total billed charges,90% of total billed charges,418.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,820.97,68.7,,,percent of total billed charges,68.7% of total billed charges,956,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,693.1,58,,,percent of total billed charges,58% of total billed charges,243.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1015.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,1075.5,
RETRACTOR IRIS,7950006,CDM,270,RC,,,Outpatient,,,1195,956,,1015.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,243.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,675.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,675.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,675.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,675.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1075.5,90,,,percent of total billed charges,90% of total billed charges,418.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,820.97,68.7,,,percent of total billed charges,68.7% of total billed charges,956,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,693.1,58,,,percent of total billed charges,58% of total billed charges,243.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1015.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,243.42,1075.5,
US PHYSL SEG EXERCISE-BIL,4600014,CDM,921,RC,93924,HCPCS,Outpatient,,,1215,972,,1032.75,85,,,percent of total billed charges,85% of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,320.22,130,,,fee schedule,Pays 130% Medicare OPPS,247.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,686.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,686.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,686.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,686.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,242.49,102,,,fee schedule,Pays 102% Medicare OPPS,1093.5,90,,,percent of total billed charges,90% of total billed charges,425.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,834.71,68.7,,,percent of total billed charges,68.7% of total billed charges,972,80,,,percent of total billed charges,80 percent of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,213.96,90,,,fee schedule,Pays 90% Medicare OPPS,704.7,58,,,percent of total billed charges,58% of total billed charges,247.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,246.33,100,,,fee schedule,Pays 100% Medicare OPPS,320.22,130,,,fee schedule,Pays 130% Medicare OPPS,1032.75,85,,,percent of total billed charges,85% of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,213.96,1093.5,
OR ACUITY LEVEL 1-A 1ST HOUR,1501147,CDM,360,RC,,,Outpatient,,,1220,976,,1037,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,248.51,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,689.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,689.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,689.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,689.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1098,90,,,percent of total billed charges,90% of total billed charges,427,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,838.14,68.7,,,percent of total billed charges,68.7% of total billed charges,976,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,707.6,58,,,percent of total billed charges,58% of total billed charges,248.51,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1037,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,248.51,1098,
HERNIA SYSTEM PROLENE MEDIUM PHSM6,1570066,CDM,278,RC,C1781,HCPCS,Both,,,1220,976,,1037,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,248.51,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,636.49,52.17,,,case rate,100% of BCBS case rate,636.49,52.17,,,case rate,100% of BCBS case rate,636.49,52.17,,,case rate,100% of BCBS case rate,636.49,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1098,90,,,percent of total billed charges,90% of total billed charges,427,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,838.14,68.7,,,percent of total billed charges,68.7% of total billed charges,976,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,707.6,58,,,percent of total billed charges,58% of total billed charges,248.51,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1037,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,248.51,1098,
.TISSUE CULTURE NON NEOPLA,3000305,CDM,311,RC,88230,HCPCS,Outpatient,,,1220,976,,1037,85,,,percent of total billed charges,85% of total billed charges,116.49,100,,,fee schedule,Pays 100% Medicare OPPS,116.49,100,,,fee schedule,Pays 100% Medicare OPPS,116.49,100,,,fee schedule,Pays 100% Medicare OPPS,151.43,130,APC,,fee schedule,Pays 130% Medicare OPPS,176.33,120.37,,,fee schedule,120.37% of custom fee schedule,689.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,689.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,689.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,689.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,118.81,102,,,fee schedule,Pays 102% Medicare OPPS,1098,90,,,percent of total billed charges,90% of total billed charges,183.38,125.18,,,fee schedule,125.18% of custom fee schedule,838.14,68.7,,,percent of total billed charges,68.7% of total billed charges,976,80,,,percent of total billed charges,80 percent of total billed charges,116.49,100,,,fee schedule,Pays 100% Medicare OPPS,104.84,90,,,fee schedule,Pays 90% Medicare OPPS,707.6,58,,,percent of total billed charges,58% of total billed charges,176.33,120.37,,,fee schedule,120.37% of custom fee schedule,116.49,100,,,fee schedule,Pays 100% Medicare OPPS,151.43,130,APC,,fee schedule,Pays 130% Medicare OPPS,1037,85,,,percent of total billed charges,85% of total billed charges,116.49,100,,,fee schedule,Pays 100% Medicare OPPS,104.84,1098,
XR BARIUM ENEMA - BE,4074270,CDM,320,RC,74270,HCPCS,Outpatient,,,1220,976,,1037,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.21,130,,,fee schedule,Pays 130% Medicare OPPS,248.51,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,689.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,689.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,689.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,685.64,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.67,102,,,fee schedule,Pays 102% Medicare OPPS,1098,90,,,percent of total billed charges,90% of total billed charges,427,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,838.14,68.7,,,percent of total billed charges,68.7% of total billed charges,976,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,707.6,58,,,percent of total billed charges,58% of total billed charges,248.51,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.21,130,,,fee schedule,Pays 130% Medicare OPPS,1037,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,1098,
VENTILATOR INITIAL,5594002,CDM,410,RC,94002,HCPCS,Outpatient,,,1235,988,,1049.75,85,,,percent of total billed charges,85% of total billed charges,437.62,100,,,fee schedule,Pays 100% Medicare OPPS,437.62,100,,,fee schedule,Pays 100% Medicare OPPS,437.62,100,,,fee schedule,Pays 100% Medicare OPPS,636.58,130,,,fee schedule,Pays 130% Medicare OPPS,251.57,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,697.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,697.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,697.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,697.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,446.37,102,,,fee schedule,Pays 102% Medicare OPPS,1111.5,90,,,percent of total billed charges,90% of total billed charges,432.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,848.45,68.7,,,percent of total billed charges,68.7% of total billed charges,988,80,,,percent of total billed charges,80 percent of total billed charges,437.62,100,,,fee schedule,Pays 100% Medicare OPPS,393.85,90,,,fee schedule,Pays 90% Medicare OPPS,716.3,58,,,percent of total billed charges,58% of total billed charges,251.57,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,489.68,100,,,fee schedule,Pays 100% Medicare OPPS,636.58,130,,,fee schedule,Pays 130% Medicare OPPS,1049.75,85,,,percent of total billed charges,85% of total billed charges,437.62,100,,,fee schedule,Pays 100% Medicare OPPS,251.57,1111.5,
VENT MGMT INPAT SUBQ DAY,5594003,CDM,410,RC,94003,HCPCS,Outpatient,,,1235,988,,1049.75,85,,,percent of total billed charges,85% of total billed charges,437.62,100,,,fee schedule,Pays 100% Medicare OPPS,437.62,100,,,fee schedule,Pays 100% Medicare OPPS,437.62,100,,,fee schedule,Pays 100% Medicare OPPS,636.58,130,,,fee schedule,Pays 130% Medicare OPPS,251.57,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,697.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,697.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,697.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,697.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,446.37,102,,,fee schedule,Pays 102% Medicare OPPS,1111.5,90,,,percent of total billed charges,90% of total billed charges,432.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,848.45,68.7,,,percent of total billed charges,68.7% of total billed charges,988,80,,,percent of total billed charges,80 percent of total billed charges,437.62,100,,,fee schedule,Pays 100% Medicare OPPS,393.85,90,,,fee schedule,Pays 90% Medicare OPPS,716.3,58,,,percent of total billed charges,58% of total billed charges,251.57,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,489.68,100,,,fee schedule,Pays 100% Medicare OPPS,636.58,130,,,fee schedule,Pays 130% Medicare OPPS,1049.75,85,,,percent of total billed charges,85% of total billed charges,437.62,100,,,fee schedule,Pays 100% Medicare OPPS,251.57,1111.5,
BIPAP INITIAL,5594656,CDM,410,RC,94002,HCPCS,Outpatient,,,1235,988,,1049.75,85,,,percent of total billed charges,85% of total billed charges,437.62,100,,,fee schedule,Pays 100% Medicare OPPS,437.62,100,,,fee schedule,Pays 100% Medicare OPPS,437.62,100,,,fee schedule,Pays 100% Medicare OPPS,636.58,130,,,fee schedule,Pays 130% Medicare OPPS,251.57,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,697.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,697.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,697.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,697.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,446.37,102,,,fee schedule,Pays 102% Medicare OPPS,1111.5,90,,,percent of total billed charges,90% of total billed charges,432.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,848.45,68.7,,,percent of total billed charges,68.7% of total billed charges,988,80,,,percent of total billed charges,80 percent of total billed charges,437.62,100,,,fee schedule,Pays 100% Medicare OPPS,393.85,90,,,fee schedule,Pays 90% Medicare OPPS,716.3,58,,,percent of total billed charges,58% of total billed charges,251.57,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,489.68,100,,,fee schedule,Pays 100% Medicare OPPS,636.58,130,,,fee schedule,Pays 130% Medicare OPPS,1049.75,85,,,percent of total billed charges,85% of total billed charges,437.62,100,,,fee schedule,Pays 100% Medicare OPPS,251.57,1111.5,
EXCISION OF LESSION MOUTH W/SIMPLE REPAI,2040812,CDM,450,RC,40812,HCPCS,Outpatient,,,1245,996,,1058.25,85,,,percent of total billed charges,85% of total billed charges,1215.17,100,,,fee schedule,Pays 100% Medicare OPPS,1215.17,100,,,fee schedule,Pays 100% Medicare OPPS,1215.17,100,,,fee schedule,Pays 100% Medicare OPPS,1587.27,130,,,fee schedule,Pays 130% Medicare OPPS,253.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,703.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,703.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,703.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,703.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1239.47,102,,,fee schedule,Pays 102% Medicare OPPS,1120.5,90,,,percent of total billed charges,90% of total billed charges,435.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,855.32,68.7,,,percent of total billed charges,68.7% of total billed charges,996,80,,,percent of total billed charges,80 percent of total billed charges,1215.17,100,,,fee schedule,Pays 100% Medicare OPPS,1093.65,90,,,fee schedule,Pays 90% Medicare OPPS,722.1,58,,,percent of total billed charges,58% of total billed charges,253.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1220.98,100,,,fee schedule,Pays 100% Medicare OPPS,1587.27,130,,,fee schedule,Pays 130% Medicare OPPS,1058.25,85,,,percent of total billed charges,85% of total billed charges,1215.17,100,,,fee schedule,Pays 100% Medicare OPPS,253.61,1587.27,
REMOVE EMBEDDED FB EYELID,2067938,CDM,450,RC,67938,HCPCS,Outpatient,,,1245,996,,1058.25,85,,,percent of total billed charges,85% of total billed charges,234.98,100,,,fee schedule,Pays 100% Medicare OPPS,234.98,100,,,fee schedule,Pays 100% Medicare OPPS,234.98,100,,,fee schedule,Pays 100% Medicare OPPS,302.68,130,,,fee schedule,Pays 130% Medicare OPPS,253.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,703.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,703.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,703.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,703.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,239.68,102,,,fee schedule,Pays 102% Medicare OPPS,1120.5,90,,,percent of total billed charges,90% of total billed charges,435.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,855.32,68.7,,,percent of total billed charges,68.7% of total billed charges,996,80,,,percent of total billed charges,80 percent of total billed charges,234.98,100,,,fee schedule,Pays 100% Medicare OPPS,211.48,90,,,fee schedule,Pays 90% Medicare OPPS,722.1,58,,,percent of total billed charges,58% of total billed charges,253.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,232.82,100,,,fee schedule,Pays 100% Medicare OPPS,302.68,130,,,fee schedule,Pays 130% Medicare OPPS,1058.25,85,,,percent of total billed charges,85% of total billed charges,234.98,100,,,fee schedule,Pays 100% Medicare OPPS,211.48,1120.5,
ATROVENT (IPRATROPIUM BROM) INH :,2600035,CDM,250,RC,,,Outpatient,,,1245,996,,1058.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,253.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,703.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,703.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,703.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,703.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1120.5,90,,,percent of total billed charges,90% of total billed charges,435.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,855.32,68.7,,,percent of total billed charges,68.7% of total billed charges,996,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,722.1,58,,,percent of total billed charges,58% of total billed charges,253.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1058.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,253.61,1120.5,
BIPAP SUBSEQUENT,5594657,CDM,410,RC,94003,HCPCS,Outpatient,,,1250,1000,,1062.5,85,,,percent of total billed charges,85% of total billed charges,437.62,100,,,fee schedule,Pays 100% Medicare OPPS,437.62,100,,,fee schedule,Pays 100% Medicare OPPS,437.62,100,,,fee schedule,Pays 100% Medicare OPPS,636.58,130,,,fee schedule,Pays 130% Medicare OPPS,254.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,706.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,706.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,706.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,706.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,446.37,102,,,fee schedule,Pays 102% Medicare OPPS,1125,90,,,percent of total billed charges,90% of total billed charges,437.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,858.75,68.7,,,percent of total billed charges,68.7% of total billed charges,1000,80,,,percent of total billed charges,80 percent of total billed charges,437.62,100,,,fee schedule,Pays 100% Medicare OPPS,393.85,90,,,fee schedule,Pays 90% Medicare OPPS,725,58,,,percent of total billed charges,58% of total billed charges,254.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,489.68,100,,,fee schedule,Pays 100% Medicare OPPS,636.58,130,,,fee schedule,Pays 130% Medicare OPPS,1062.5,85,,,percent of total billed charges,85% of total billed charges,437.62,100,,,fee schedule,Pays 100% Medicare OPPS,254.63,1125,
DUOVISC (PROVISC/VISCOTE) EA,2602575,CDM,637,RC,,,Outpatient,,,1260,1008,,1071,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,256.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,711.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,711.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,711.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,711.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1134,90,,,percent of total billed charges,90% of total billed charges,441,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,865.62,68.7,,,percent of total billed charges,68.7% of total billed charges,1008,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,730.8,58,,,percent of total billed charges,58% of total billed charges,256.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1071,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,256.66,1134,
US CAROTID UNI LEFT,4600011,CDM,921,RC,93882,HCPCS,Outpatient,,,1260,1008,,1071,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,256.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,711.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,711.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,711.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,711.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,1134,90,,,percent of total billed charges,90% of total billed charges,441,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,865.62,68.7,,,percent of total billed charges,68.7% of total billed charges,1008,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,730.8,58,,,percent of total billed charges,58% of total billed charges,256.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,1071,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,1134,
US CAROTID UNI RIGHT,4693882,CDM,320,RC,93882,HCPCS,Outpatient,,,1260,1008,,1071,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,256.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,711.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,711.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,711.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,708.12,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,1134,90,,,percent of total billed charges,90% of total billed charges,441,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,865.62,68.7,,,percent of total billed charges,68.7% of total billed charges,1008,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,730.8,58,,,percent of total billed charges,58% of total billed charges,256.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,1071,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,1134,
STRESS TEST (TREADMILL),5693017,CDM,482,RC,93017,HCPCS,Outpatient,,,1265,1012,,1075.25,85,,,percent of total billed charges,85% of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,320.23,130,,,fee schedule,Pays 130% Medicare OPPS,257.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,242.49,102,,,fee schedule,Pays 102% Medicare OPPS,1138.5,90,,,percent of total billed charges,90% of total billed charges,442.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,869.06,68.7,,,percent of total billed charges,68.7% of total billed charges,1012,80,,,percent of total billed charges,80 percent of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,213.96,90,,,fee schedule,Pays 90% Medicare OPPS,733.7,58,,,percent of total billed charges,58% of total billed charges,257.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,246.33,100,,,fee schedule,Pays 100% Medicare OPPS,320.23,130,,,fee schedule,Pays 130% Medicare OPPS,1075.25,85,,,percent of total billed charges,85% of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,213.96,1138.5,
LINEAR CUTTER ECHELON LONG60A,7950291,CDM,272,RC,,,Outpatient,,,1275,1020,,1083.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,259.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,720.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,720.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,720.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,720.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1147.5,90,,,percent of total billed charges,90% of total billed charges,446.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,875.93,68.7,,,percent of total billed charges,68.7% of total billed charges,1020,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,739.5,58,,,percent of total billed charges,58% of total billed charges,259.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1083.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,259.72,1147.5,
SUPRANE (DESFLURANE) GAS,2600049,CDM,250,RC,,,Outpatient,,,1285,1028,,1092.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,261.75,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,726.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,726.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,726.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,726.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1156.5,90,,,percent of total billed charges,90% of total billed charges,449.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,882.8,68.7,,,percent of total billed charges,68.7% of total billed charges,1028,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,745.3,58,,,percent of total billed charges,58% of total billed charges,261.75,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1092.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,261.75,1156.5,
ANCHORLOK 2.5MM,1570060,CDM,278,RC,C1713,HCPCS,Both,,,1290,1032,,1096.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,262.77,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,673.01,52.17,,,case rate,100% of BCBS case rate,673.01,52.17,,,case rate,100% of BCBS case rate,673.01,52.17,,,case rate,100% of BCBS case rate,673.01,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1161,90,,,percent of total billed charges,90% of total billed charges,451.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,886.23,68.7,,,percent of total billed charges,68.7% of total billed charges,1032,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,748.2,58,,,percent of total billed charges,58% of total billed charges,262.77,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1096.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,262.77,1161,
Fine Needle Aspiration Biopsy without imaging,2010021,CDM,450,RC,10021,HCPCS,Outpatient,,,1290,1032,,1096.5,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,262.77,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,728.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,728.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,728.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,728.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,316.7,102,,,fee schedule,Pays 102% Medicare OPPS,1161,90,,,percent of total billed charges,90% of total billed charges,451.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,886.23,68.7,,,percent of total billed charges,68.7% of total billed charges,1032,80,,,percent of total billed charges,80 percent of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,279.44,90,,,fee schedule,Pays 90% Medicare OPPS,748.2,58,,,percent of total billed charges,58% of total billed charges,262.77,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,328.14,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,1096.5,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,262.77,1161,
JAGTOME RX 39 260CM,1750027,CDM,272,RC,,,Outpatient,,,1300,1040,,1105,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,264.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,734.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,734.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,734.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,734.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1170,90,,,percent of total billed charges,90% of total billed charges,455,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,893.1,68.7,,,percent of total billed charges,68.7% of total billed charges,1040,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,754,58,,,percent of total billed charges,58% of total billed charges,264.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1105,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,264.81,1170,
JAGTOME RX 39 450CM,1750058,CDM,272,RC,,,Outpatient,,,1300,1040,,1105,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,264.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,734.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,734.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,734.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,734.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1170,90,,,percent of total billed charges,90% of total billed charges,455,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,893.1,68.7,,,percent of total billed charges,68.7% of total billed charges,1040,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,754,58,,,percent of total billed charges,58% of total billed charges,264.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1105,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,264.81,1170,
One sided or limited bilateral study,4693971,CDM,921,RC,93971,HCPCS,Outpatient,,,1300,1040,,1105,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,264.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,734.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,734.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,734.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,734.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,1170,90,,,percent of total billed charges,90% of total billed charges,455,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,893.1,68.7,,,percent of total billed charges,68.7% of total billed charges,1040,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,754,58,,,percent of total billed charges,58% of total billed charges,264.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,1105,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,1170,
POWERPORT IMPLANTABLE PORT 1708000,7905967,CDM,278,RC,C1751,HCPCS,Both,,,1300,1040,,1105,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,264.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,678.22,52.17,,,case rate,100% of BCBS case rate,678.22,52.17,,,case rate,100% of BCBS case rate,678.22,52.17,,,case rate,100% of BCBS case rate,678.22,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1170,90,,,percent of total billed charges,90% of total billed charges,455,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,893.1,68.7,,,percent of total billed charges,68.7% of total billed charges,1040,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,754,58,,,percent of total billed charges,58% of total billed charges,264.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1105,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,264.81,1170,
CRITICAL CARE FOR NEWBORN,501159,CDM,171,RC,99468,HCPCS,Inpatient,,,1310,1048,,950,100,,,per diem,Per day rate of 950,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1886.9,100,,,per diem,100% of BCBS case rate,1886.9,100,,,per diem,100% of BCBS case rate,1886.9,100,,,per diem,100% of BCBS case rate,2100.6,100,,,per diem,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1179,90,,,percent of total billed charges,90% of total billed charges,,100,,,case rate,Not reimbursable per contract,899.97,68.7,,,percent of total billed charges,68.7% of total billed charges,600,100,,,per diem,Per Day Rate of $600,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1100,100,,,per diem,per day rate of $1100,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1113.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,600,2100.6,
ANES LUMBAR PUNCTURE,1800635,CDM,379,RC,635,HCPCS,Outpatient,,,1310,1048,,1113.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,266.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,740.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,740.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,740.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,740.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1179,90,,,percent of total billed charges,90% of total billed charges,458.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,899.97,68.7,,,percent of total billed charges,68.7% of total billed charges,1048,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,759.8,58,,,percent of total billed charges,58% of total billed charges,266.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,266.85,1179,
Ultrasound of single fetus,4676811,CDM,402,RC,76811,HCPCS,Outpatient,,,1310,1048,,1113.5,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,266.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,740.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,740.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,740.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,736.22,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,1179,90,,,percent of total billed charges,90% of total billed charges,458.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,899.97,68.7,,,percent of total billed charges,68.7% of total billed charges,1048,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,759.8,58,,,percent of total billed charges,58% of total billed charges,266.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1113.5,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,1179,
US FETAL GROWTH PARA IURG FOLLOW-UP,4676816,CDM,402,RC,76816,HCPCS,Outpatient,,,1310,1048,,1113.5,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,266.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,740.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,740.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,740.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,736.22,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,1179,90,,,percent of total billed charges,90% of total billed charges,458.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,899.97,68.7,,,percent of total billed charges,68.7% of total billed charges,1048,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,90,,,fee schedule,Pays 90% Medicare OPPS,759.8,58,,,percent of total billed charges,58% of total billed charges,266.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94,100,,,fee schedule,Pays 100% Medicare OPPS,122.21,130,,,fee schedule,Pays 130% Medicare OPPS,1113.5,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.02,1179,
HERNIA REPAIR W/MESH,1549568,CDM,360,RC,49568,HCPCS,Outpatient,,,1315,1052,,1117.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,267.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,,,,,other,Not reimbursable per contract,1183.5,90,,,percent of total billed charges,90% of total billed charges,460.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,903.41,68.7,,,percent of total billed charges,68.7% of total billed charges,1052,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,762.7,58,,,percent of total billed charges,58% of total billed charges,267.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1117.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,267.87,1183.5,
CUT DOWN INFANT,2036490,CDM,450,RC,36555,HCPCS,Outpatient,,,1315,1052,,1117.75,85,,,percent of total billed charges,85% of total billed charges,2571.56,100,,,fee schedule,Pays 100% Medicare OPPS,2571.56,100,,,fee schedule,Pays 100% Medicare OPPS,2571.56,100,,,fee schedule,Pays 100% Medicare OPPS,3406.31,130,,,fee schedule,Pays 130% Medicare OPPS,267.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,742.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,742.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,742.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,742.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2622.99,102,,,fee schedule,Pays 102% Medicare OPPS,1183.5,90,,,percent of total billed charges,90% of total billed charges,460.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,903.41,68.7,,,percent of total billed charges,68.7% of total billed charges,1052,80,,,percent of total billed charges,80 percent of total billed charges,2571.56,100,,,fee schedule,Pays 100% Medicare OPPS,2314.4,90,,,fee schedule,Pays 90% Medicare OPPS,762.7,58,,,percent of total billed charges,58% of total billed charges,267.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2620.23,100,,,fee schedule,Pays 100% Medicare OPPS,3406.31,130,,,fee schedule,Pays 130% Medicare OPPS,1117.75,85,,,percent of total billed charges,85% of total billed charges,2571.56,100,,,fee schedule,Pays 100% Medicare OPPS,267.87,3406.31,
CUT DOWN CHILD/ADULT,2036491,CDM,450,RC,,,Outpatient,,,1315,1052,,1117.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,267.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,742.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,742.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,742.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,742.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1183.5,90,,,percent of total billed charges,90% of total billed charges,460.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,903.41,68.7,,,percent of total billed charges,68.7% of total billed charges,1052,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,762.7,58,,,percent of total billed charges,58% of total billed charges,267.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1117.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,267.87,1183.5,
CERVIDIL (DINOPROSTONE) VAG SUPP,2600206,CDM,637,RC,,,Outpatient,,,1315,1052,,1117.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,267.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,742.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,742.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,742.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,742.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1183.5,90,,,percent of total billed charges,90% of total billed charges,460.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,903.41,68.7,,,percent of total billed charges,68.7% of total billed charges,1052,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,762.7,58,,,percent of total billed charges,58% of total billed charges,267.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1117.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,267.87,1183.5,
US PHYS UP/LOW ART/MULTI-BIL,4693923,CDM,921,RC,93923,HCPCS,Outpatient,,,1315,1052,,1117.75,85,,,percent of total billed charges,85% of total billed charges,125.42,100,,,fee schedule,Pays 100% Medicare OPPS,125.42,100,,,fee schedule,Pays 100% Medicare OPPS,125.42,100,,,fee schedule,Pays 100% Medicare OPPS,166.28,130,,,fee schedule,Pays 130% Medicare OPPS,267.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,742.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,742.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,742.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,742.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,127.92,102,,,fee schedule,Pays 102% Medicare OPPS,1183.5,90,,,percent of total billed charges,90% of total billed charges,460.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,903.41,68.7,,,percent of total billed charges,68.7% of total billed charges,1052,80,,,percent of total billed charges,80 percent of total billed charges,125.42,100,,,fee schedule,Pays 100% Medicare OPPS,112.87,90,,,fee schedule,Pays 90% Medicare OPPS,762.7,58,,,percent of total billed charges,58% of total billed charges,267.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,127.91,100,,,fee schedule,Pays 100% Medicare OPPS,166.28,130,,,fee schedule,Pays 130% Medicare OPPS,1117.75,85,,,percent of total billed charges,85% of total billed charges,125.42,100,,,fee schedule,Pays 100% Medicare OPPS,112.87,1183.5,
MARLEX MESH 1.8 X 4,7905794,CDM,278,RC,,,Both,,,1315,1052,,1117.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,267.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,686.05,52.17,,,case rate,100% of BCBS case rate,686.05,52.17,,,case rate,100% of BCBS case rate,686.05,52.17,,,case rate,100% of BCBS case rate,686.05,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1183.5,90,,,percent of total billed charges,90% of total billed charges,460.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,903.41,68.7,,,percent of total billed charges,68.7% of total billed charges,1052,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,762.7,58,,,percent of total billed charges,58% of total billed charges,267.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1117.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,267.87,1183.5,
SINUS BALLOON SYSTEM SINUS GUIDE,1570763,CDM,272,RC,,,Outpatient,,,1325,1060,,1126.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,269.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,748.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,748.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,748.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,748.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1192.5,90,,,percent of total billed charges,90% of total billed charges,463.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,910.28,68.7,,,percent of total billed charges,68.7% of total billed charges,1060,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,768.5,58,,,percent of total billed charges,58% of total billed charges,269.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1126.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,269.9,1192.5,
GOLD PROBE 6015,1750014,CDM,272,RC,,,Outpatient,,,1335,1068,,1134.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,271.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,754.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,754.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,754.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,754.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1201.5,90,,,percent of total billed charges,90% of total billed charges,467.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,917.15,68.7,,,percent of total billed charges,68.7% of total billed charges,1068,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,774.3,58,,,percent of total billed charges,58% of total billed charges,271.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1134.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,271.94,1201.5,
Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries,4600012,CDM,921,RC,93922,HCPCS,Outpatient,,,1335,1068,,1134.75,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,271.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,754.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,754.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,754.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,754.28,56.5,,,percent of total billed charges,56.5 percent of total billed charges,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,1201.5,90,,,percent of total billed charges,90% of total billed charges,467.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,917.15,68.7,,,percent of total billed charges,68.7% of total billed charges,1068,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,774.3,58,,,percent of total billed charges,58% of total billed charges,271.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,1134.75,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,1201.5,
FORCEP HOT BIOPSY,7950070,CDM,272,RC,,,Outpatient,,,1345,1076,,1143.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,273.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,759.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,759.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,759.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,759.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1210.5,90,,,percent of total billed charges,90% of total billed charges,470.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,924.02,68.7,,,percent of total billed charges,68.7% of total billed charges,1076,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,780.1,58,,,percent of total billed charges,58% of total billed charges,273.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1143.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,273.98,1210.5,
LENS INTRAOCULAR SN60T3 21.0,1570175,CDM,276,RC,V2797,HCPCS,Outpatient,,,1360,1088,,1156,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1224,90,,,percent of total billed charges,90% of total billed charges,476,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,934.32,68.7,,,percent of total billed charges,68.7% of total billed charges,1088,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,788.8,58,,,percent of total billed charges,58% of total billed charges,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1156,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,277.03,1224,
LENS INTRAOCULAR SN60T3 21.5,1570176,CDM,276,RC,V2797,HCPCS,Outpatient,,,1360,1088,,1156,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1224,90,,,percent of total billed charges,90% of total billed charges,476,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,934.32,68.7,,,percent of total billed charges,68.7% of total billed charges,1088,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,788.8,58,,,percent of total billed charges,58% of total billed charges,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1156,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,277.03,1224,
LENS INTRAOCULAR SN60T5 19.0,1570177,CDM,276,RC,V2797,HCPCS,Outpatient,,,1360,1088,,1156,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1224,90,,,percent of total billed charges,90% of total billed charges,476,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,934.32,68.7,,,percent of total billed charges,68.7% of total billed charges,1088,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,788.8,58,,,percent of total billed charges,58% of total billed charges,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1156,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,277.03,1224,
LENS INTRAOCULAR SN60T5 22.0,1570188,CDM,276,RC,V2797,HCPCS,Outpatient,,,1360,1088,,1156,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1224,90,,,percent of total billed charges,90% of total billed charges,476,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,934.32,68.7,,,percent of total billed charges,68.7% of total billed charges,1088,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,788.8,58,,,percent of total billed charges,58% of total billed charges,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1156,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,277.03,1224,
LENS INTRAOCULAR SN60T4 24.5,1570189,CDM,276,RC,V2797,HCPCS,Outpatient,,,1360,1088,,1156,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1224,90,,,percent of total billed charges,90% of total billed charges,476,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,934.32,68.7,,,percent of total billed charges,68.7% of total billed charges,1088,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,788.8,58,,,percent of total billed charges,58% of total billed charges,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1156,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,277.03,1224,
LENS INTRAOCULAR SN60T5 29.0,1570190,CDM,276,RC,V2797,HCPCS,Outpatient,,,1360,1088,,1156,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1224,90,,,percent of total billed charges,90% of total billed charges,476,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,934.32,68.7,,,percent of total billed charges,68.7% of total billed charges,1088,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,788.8,58,,,percent of total billed charges,58% of total billed charges,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1156,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,277.03,1224,
LENS INTRAOCULAR SN60T5 12.5,1570191,CDM,276,RC,V2797,HCPCS,Outpatient,,,1360,1088,,1156,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1224,90,,,percent of total billed charges,90% of total billed charges,476,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,934.32,68.7,,,percent of total billed charges,68.7% of total billed charges,1088,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,788.8,58,,,percent of total billed charges,58% of total billed charges,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1156,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,277.03,1224,
LENS INTRAOCULAR SN60T4 29.5,1570192,CDM,276,RC,V2797,HCPCS,Outpatient,,,1360,1088,,1156,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1224,90,,,percent of total billed charges,90% of total billed charges,476,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,934.32,68.7,,,percent of total billed charges,68.7% of total billed charges,1088,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,788.8,58,,,percent of total billed charges,58% of total billed charges,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1156,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,277.03,1224,
LENS INTRAOCULAR SN60T4 15.5,1570193,CDM,276,RC,V2797,HCPCS,Outpatient,,,1360,1088,,1156,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1224,90,,,percent of total billed charges,90% of total billed charges,476,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,934.32,68.7,,,percent of total billed charges,68.7% of total billed charges,1088,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,788.8,58,,,percent of total billed charges,58% of total billed charges,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1156,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,277.03,1224,
LENS INTRAOCULAR SN6AT4 19.0,1570195,CDM,276,RC,V2797,HCPCS,Outpatient,,,1360,1088,,1156,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1224,90,,,percent of total billed charges,90% of total billed charges,476,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,934.32,68.7,,,percent of total billed charges,68.7% of total billed charges,1088,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,788.8,58,,,percent of total billed charges,58% of total billed charges,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1156,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,277.03,1224,
LENS INTRAOCULAR SN6AT4 30.0,1570196,CDM,276,RC,V2797,HCPCS,Outpatient,,,1360,1088,,1156,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1224,90,,,percent of total billed charges,90% of total billed charges,476,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,934.32,68.7,,,percent of total billed charges,68.7% of total billed charges,1088,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,788.8,58,,,percent of total billed charges,58% of total billed charges,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1156,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,277.03,1224,
LENS INTRAOCULAR SN6AT4 22.5,1570205,CDM,276,RC,V2797,HCPCS,Outpatient,,,1360,1088,,1156,85,,,percent of total billed charges,85% of total billed charges,340,100,,,fee schedule,Pays 100% Medicare OPPS,340,100,,,fee schedule,Pays 100% Medicare OPPS,340,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1224,90,,,percent of total billed charges,90% of total billed charges,476,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,934.32,68.7,,,percent of total billed charges,68.7% of total billed charges,1088,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1224,90,,,fee schedule,Pays 90% Medicare OPPS,788.8,58,,,percent of total billed charges,58% of total billed charges,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1156,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,277.03,1224,
LENS INTRAOCULAR SN6AT4 21.5,1570206,CDM,276,RC,V2797,HCPCS,Outpatient,,,1360,1088,,1156,85,,,percent of total billed charges,85% of total billed charges,340,100,,,fee schedule,Pays 100% Medicare OPPS,340,100,,,fee schedule,Pays 100% Medicare OPPS,340,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1224,90,,,percent of total billed charges,90% of total billed charges,476,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,934.32,68.7,,,percent of total billed charges,68.7% of total billed charges,1088,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1224,90,,,fee schedule,Pays 90% Medicare OPPS,788.8,58,,,percent of total billed charges,58% of total billed charges,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1156,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,277.03,1224,
LENS INTRAOCULAR SN6AT3 13.0,1570283,CDM,276,RC,V2797,HCPCS,Outpatient,,,1360,1088,,1156,85,,,percent of total billed charges,85% of total billed charges,340,100,,,fee schedule,Pays 100% Medicare OPPS,340,100,,,fee schedule,Pays 100% Medicare OPPS,340,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1224,90,,,percent of total billed charges,90% of total billed charges,476,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,934.32,68.7,,,percent of total billed charges,68.7% of total billed charges,1088,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1224,90,,,fee schedule,Pays 90% Medicare OPPS,788.8,58,,,percent of total billed charges,58% of total billed charges,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1156,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,277.03,1224,
LENS INTRAOCULAR SN6AT3 19.0,1570284,CDM,276,RC,V2797,HCPCS,Outpatient,,,1360,1088,,1156,85,,,percent of total billed charges,85% of total billed charges,340,100,,,fee schedule,Pays 100% Medicare OPPS,340,100,,,fee schedule,Pays 100% Medicare OPPS,340,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1224,90,,,percent of total billed charges,90% of total billed charges,476,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,934.32,68.7,,,percent of total billed charges,68.7% of total billed charges,1088,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1224,90,,,fee schedule,Pays 90% Medicare OPPS,788.8,58,,,percent of total billed charges,58% of total billed charges,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1156,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,277.03,1224,
LENS INTRAOCULAR SN6AT3 21.5,1570285,CDM,276,RC,V2797,HCPCS,Outpatient,,,1360,1088,,1156,85,,,percent of total billed charges,85% of total billed charges,340,100,,,fee schedule,Pays 100% Medicare OPPS,340,100,,,fee schedule,Pays 100% Medicare OPPS,340,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1224,90,,,percent of total billed charges,90% of total billed charges,476,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,934.32,68.7,,,percent of total billed charges,68.7% of total billed charges,1088,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1224,90,,,fee schedule,Pays 90% Medicare OPPS,788.8,58,,,percent of total billed charges,58% of total billed charges,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1156,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,277.03,1224,
LENS INTRAOCULAR SN6AT3 22.0,1570286,CDM,276,RC,V2797,HCPCS,Outpatient,,,1360,1088,,1156,85,,,percent of total billed charges,85% of total billed charges,340,100,,,fee schedule,Pays 100% Medicare OPPS,340,100,,,fee schedule,Pays 100% Medicare OPPS,340,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1224,90,,,percent of total billed charges,90% of total billed charges,476,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,934.32,68.7,,,percent of total billed charges,68.7% of total billed charges,1088,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1224,90,,,fee schedule,Pays 90% Medicare OPPS,788.8,58,,,percent of total billed charges,58% of total billed charges,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1156,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,277.03,1224,
LENS INTRAOCULAR SN6AT3 19.5,1570287,CDM,276,RC,V2797,HCPCS,Outpatient,,,1360,1088,,1156,85,,,percent of total billed charges,85% of total billed charges,340,100,,,fee schedule,Pays 100% Medicare OPPS,340,100,,,fee schedule,Pays 100% Medicare OPPS,340,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1224,90,,,percent of total billed charges,90% of total billed charges,476,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,934.32,68.7,,,percent of total billed charges,68.7% of total billed charges,1088,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1224,90,,,fee schedule,Pays 90% Medicare OPPS,788.8,58,,,percent of total billed charges,58% of total billed charges,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1156,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,277.03,1224,
LENS INTRAOCULAR SN6AT8 21.5,1570288,CDM,276,RC,V2797,HCPCS,Outpatient,,,1360,1088,,1156,85,,,percent of total billed charges,85% of total billed charges,340,100,,,fee schedule,Pays 100% Medicare OPPS,340,100,,,fee schedule,Pays 100% Medicare OPPS,340,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1224,90,,,percent of total billed charges,90% of total billed charges,476,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,934.32,68.7,,,percent of total billed charges,68.7% of total billed charges,1088,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1224,90,,,fee schedule,Pays 90% Medicare OPPS,788.8,58,,,percent of total billed charges,58% of total billed charges,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1156,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,277.03,1224,
LENS INTRAOCULAR SN60T4 21.0,1750175,CDM,276,RC,V2797,HCPCS,Outpatient,,,1360,1088,,1156,85,,,percent of total billed charges,85% of total billed charges,340,100,,,fee schedule,Pays 100% Medicare OPPS,340,100,,,fee schedule,Pays 100% Medicare OPPS,340,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,709.53,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1224,90,,,percent of total billed charges,90% of total billed charges,476,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,934.32,68.7,,,percent of total billed charges,68.7% of total billed charges,1088,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1224,90,,,fee schedule,Pays 90% Medicare OPPS,788.8,58,,,percent of total billed charges,58% of total billed charges,277.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1156,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,277.03,1224,
3RD HIV GENOTYPE,3000151,CDM,300,RC,87901,HCPCS,Outpatient,,,1360,1088,,1156,85,,,percent of total billed charges,85% of total billed charges,257.45,100,,,fee schedule,Pays 100% Medicare OPPS,257.45,100,,,fee schedule,Pays 100% Medicare OPPS,257.45,100,,,fee schedule,Pays 100% Medicare OPPS,334.68,130,,,fee schedule,Pays 130% Medicare OPPS,132.01,120.37,,,fee schedule,120.37% of custom fee schedule,768.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,768.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,768.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,768.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,262.59,102,,,fee schedule,Pays 102% Medicare OPPS,1224,90,,,percent of total billed charges,90% of total billed charges,137.28,125.18,,,fee schedule,125.18% of custom fee schedule,934.32,68.7,,,percent of total billed charges,68.7% of total billed charges,1088,80,,,percent of total billed charges,80 percent of total billed charges,257.45,100,,,fee schedule,Pays 100% Medicare OPPS,231.7,90,,,fee schedule,Pays 90% Medicare OPPS,788.8,58,,,percent of total billed charges,58% of total billed charges,132.01,120.37,,,fee schedule,120.37% of custom fee schedule,257.45,100,,,fee schedule,Pays 100% Medicare OPPS,334.68,130,,,fee schedule,Pays 130% Medicare OPPS,1156,85,,,percent of total billed charges,85% of total billed charges,257.45,100,,,fee schedule,Pays 100% Medicare OPPS,132.01,1224,
US PHYS LOWER EXT/REST-BIL,4693924,CDM,921,RC,93924,HCPCS,Outpatient,,,1370,1096,,1164.5,85,,,percent of total billed charges,85% of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,320.22,130,,,fee schedule,Pays 130% Medicare OPPS,279.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,774.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,774.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,774.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,774.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,242.49,102,,,fee schedule,Pays 102% Medicare OPPS,1233,90,,,percent of total billed charges,90% of total billed charges,479.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,941.19,68.7,,,percent of total billed charges,68.7% of total billed charges,1096,80,,,percent of total billed charges,80 percent of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,213.96,90,,,fee schedule,Pays 90% Medicare OPPS,794.6,58,,,percent of total billed charges,58% of total billed charges,279.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,246.33,100,,,fee schedule,Pays 100% Medicare OPPS,320.22,130,,,fee schedule,Pays 130% Medicare OPPS,1164.5,85,,,percent of total billed charges,85% of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,213.96,1233,
HERNIA SYSTEM PROLENE LARGE PHSL,1570067,CDM,278,RC,C1781,HCPCS,Both,,,1375,1100,,1168.75,85,,,percent of total billed charges,85% of total billed charges,343.75,100,,,fee schedule,Pays 100% Medicare OPPS,343.75,100,,,fee schedule,Pays 100% Medicare OPPS,343.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,280.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,717.35,52.17,,,case rate,100% of BCBS case rate,717.35,52.17,,,case rate,100% of BCBS case rate,717.35,52.17,,,case rate,100% of BCBS case rate,717.35,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1237.5,90,,,percent of total billed charges,90% of total billed charges,481.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,944.63,68.7,,,percent of total billed charges,68.7% of total billed charges,1100,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1237.5,90,,,fee schedule,Pays 90% Medicare OPPS,797.5,58,,,percent of total billed charges,58% of total billed charges,280.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1168.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,280.09,1237.5,
CLOSED TREATMENT OF HIP,2027250,CDM,450,RC,27250,HCPCS,Outpatient,,,1375,1100,,1168.75,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,280.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,776.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,776.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,776.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,776.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,188.85,102,,,fee schedule,Pays 102% Medicare OPPS,1237.5,90,,,percent of total billed charges,90% of total billed charges,481.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,944.63,68.7,,,percent of total billed charges,68.7% of total billed charges,1100,80,,,percent of total billed charges,80 percent of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,166.63,90,,,fee schedule,Pays 90% Medicare OPPS,797.5,58,,,percent of total billed charges,58% of total billed charges,280.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,182.08,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,1168.75,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,166.63,1237.5,
CAPSULE BRAVO 5 PH W/DELIVERY SYSTEM,1750022,CDM,272,RC,,,Outpatient,,,1380,1104,,1173,85,,,percent of total billed charges,85% of total billed charges,345,100,,,fee schedule,Pays 100% Medicare OPPS,345,100,,,fee schedule,Pays 100% Medicare OPPS,345,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,281.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,779.7,56.5,,,percent of total billed charges,56.5 percent of total billed charges,779.7,56.5,,,percent of total billed charges,56.5 percent of total billed charges,779.7,56.5,,,percent of total billed charges,56.5 percent of total billed charges,779.7,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1242,90,,,percent of total billed charges,90% of total billed charges,483,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,948.06,68.7,,,percent of total billed charges,68.7% of total billed charges,1104,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1242,90,,,fee schedule,Pays 90% Medicare OPPS,800.4,58,,,percent of total billed charges,58% of total billed charges,281.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1173,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,281.11,1242,
SCREW BONE 2.7 X 13MM CHARLOTTE SNAP-OFF,1570033,CDM,278,RC,C1713,HCPCS,Both,,,1390,1112,,1181.5,85,,,percent of total billed charges,85% of total billed charges,347.5,100,,,fee schedule,Pays 100% Medicare OPPS,347.5,100,,,fee schedule,Pays 100% Medicare OPPS,347.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,283.14,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,725.18,52.17,,,case rate,100% of BCBS case rate,725.18,52.17,,,case rate,100% of BCBS case rate,725.18,52.17,,,case rate,100% of BCBS case rate,725.18,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1251,90,,,percent of total billed charges,90% of total billed charges,486.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,954.93,68.7,,,percent of total billed charges,68.7% of total billed charges,1112,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1251,90,,,fee schedule,Pays 90% Medicare OPPS,806.2,58,,,percent of total billed charges,58% of total billed charges,283.14,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1181.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,283.14,1251,
SCREW BONE 2.7 X 15MM CHARLOTTE SNAP-OFF,1570034,CDM,278,RC,C1713,HCPCS,Both,,,1390,1112,,1181.5,85,,,percent of total billed charges,85% of total billed charges,347.5,100,,,fee schedule,Pays 100% Medicare OPPS,347.5,100,,,fee schedule,Pays 100% Medicare OPPS,347.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,283.14,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,725.18,52.17,,,case rate,100% of BCBS case rate,725.18,52.17,,,case rate,100% of BCBS case rate,725.18,52.17,,,case rate,100% of BCBS case rate,725.18,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1251,90,,,percent of total billed charges,90% of total billed charges,486.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,954.93,68.7,,,percent of total billed charges,68.7% of total billed charges,1112,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1251,90,,,fee schedule,Pays 90% Medicare OPPS,806.2,58,,,percent of total billed charges,58% of total billed charges,283.14,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1181.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,283.14,1251,
I & D ABSCESS COMPLICATED,2010061,CDM,450,RC,,,Outpatient,,,1410,1128,,1198.5,85,,,percent of total billed charges,85% of total billed charges,352.5,100,,,fee schedule,Pays 100% Medicare OPPS,352.5,100,,,fee schedule,Pays 100% Medicare OPPS,352.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,287.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,796.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,796.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,796.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,796.65,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1269,90,,,percent of total billed charges,90% of total billed charges,493.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,968.67,68.7,,,percent of total billed charges,68.7% of total billed charges,1128,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1269,90,,,fee schedule,Pays 90% Medicare OPPS,817.8,58,,,percent of total billed charges,58% of total billed charges,287.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1198.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,287.22,1269,
NF-CUBICIN 500MG INTRAVENOUS POWDER FOR,2661964,CDM,270,RC,J0878,HCPCS,Outpatient,,,1420,1136,,1207,85,,,percent of total billed charges,85% of total billed charges,355,100,,,fee schedule,Pays 100% Medicare OPPS,355,100,,,fee schedule,Pays 100% Medicare OPPS,355,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,0.05,120.37,,,fee schedule,120.37% of custom fee schedule,802.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,802.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,802.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,802.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1278,90,,,percent of total billed charges,90% of total billed charges,0.05,125.18,,,fee schedule,125.18% of custom fee schedule,975.54,68.7,,,percent of total billed charges,68.7% of total billed charges,1136,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1278,90,,,fee schedule,Pays 90% Medicare OPPS,823.6,58,,,percent of total billed charges,58% of total billed charges,0.05,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1207,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,0.05,1278,
MM BREAST BX PERCUT NO IMAGI,4319100,CDM,401,RC,19100,HCPCS,Outpatient,,,1420,1136,,1207,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,289.25,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,802.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,802.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,802.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,798.04,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1289.21,102,,,fee schedule,Pays 102% Medicare OPPS,1278,90,,,percent of total billed charges,90% of total billed charges,497,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,975.54,68.7,,,percent of total billed charges,68.7% of total billed charges,1136,80,,,percent of total billed charges,80 percent of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1137.55,90,,,fee schedule,Pays 90% Medicare OPPS,823.6,58,,,percent of total billed charges,58% of total billed charges,289.25,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1318.97,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,1207,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,289.25,1714.66,
HERNIA PATCH KUGEL 5.5 X 7 0010102,1570009,CDM,278,RC,C1781,HCPCS,Both,,,1445,1156,,1228.25,85,,,percent of total billed charges,85% of total billed charges,361.25,100,,,fee schedule,Pays 100% Medicare OPPS,361.25,100,,,fee schedule,Pays 100% Medicare OPPS,361.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,294.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,753.87,52.17,,,case rate,100% of BCBS case rate,753.87,52.17,,,case rate,100% of BCBS case rate,753.87,52.17,,,case rate,100% of BCBS case rate,753.87,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1300.5,90,,,percent of total billed charges,90% of total billed charges,505.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,992.72,68.7,,,percent of total billed charges,68.7% of total billed charges,1156,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1300.5,90,,,fee schedule,Pays 90% Medicare OPPS,838.1,58,,,percent of total billed charges,58% of total billed charges,294.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1228.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,294.35,1300.5,
SCREW SPIN 2MM DIA--13MM LENGTH,1570074,CDM,278,RC,C1713,HCPCS,Both,,,1460,1168,,1241,85,,,percent of total billed charges,85% of total billed charges,365,100,,,fee schedule,Pays 100% Medicare OPPS,365,100,,,fee schedule,Pays 100% Medicare OPPS,365,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,297.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,761.7,52.17,,,case rate,100% of BCBS case rate,761.7,52.17,,,case rate,100% of BCBS case rate,761.7,52.17,,,case rate,100% of BCBS case rate,761.7,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1314,90,,,percent of total billed charges,90% of total billed charges,511,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1003.02,68.7,,,percent of total billed charges,68.7% of total billed charges,1168,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1314,90,,,fee schedule,Pays 90% Medicare OPPS,846.8,58,,,percent of total billed charges,58% of total billed charges,297.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1241,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,297.4,1314,
SCREW SPIN 2MM DIA--12MM LENGTH,1570076,CDM,278,RC,C1713,HCPCS,Both,,,1460,1168,,1241,85,,,percent of total billed charges,85% of total billed charges,365,100,,,fee schedule,Pays 100% Medicare OPPS,365,100,,,fee schedule,Pays 100% Medicare OPPS,365,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,297.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,761.7,52.17,,,case rate,100% of BCBS case rate,761.7,52.17,,,case rate,100% of BCBS case rate,761.7,52.17,,,case rate,100% of BCBS case rate,761.7,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1314,90,,,percent of total billed charges,90% of total billed charges,511,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1003.02,68.7,,,percent of total billed charges,68.7% of total billed charges,1168,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1314,90,,,fee schedule,Pays 90% Medicare OPPS,846.8,58,,,percent of total billed charges,58% of total billed charges,297.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1241,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,297.4,1314,
Ultrasound of back wall of the abdomen with all areas viewed,4686770,CDM,402,RC,76770,HCPCS,Outpatient,,,1460,1168,,1241,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,297.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,824.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,824.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,824.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,820.52,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,1314,90,,,percent of total billed charges,90% of total billed charges,511,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1003.02,68.7,,,percent of total billed charges,68.7% of total billed charges,1168,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,846.8,58,,,percent of total billed charges,58% of total billed charges,297.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,1241,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,1314,
XR RETROGRADE IVP,4074420,CDM,320,RC,74420,HCPCS,Outpatient,,,1465,1172,,1245.25,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,298.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,827.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,827.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,827.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,823.33,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,1318.5,90,,,percent of total billed charges,90% of total billed charges,512.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1006.46,68.7,,,percent of total billed charges,68.7% of total billed charges,1172,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,849.7,58,,,percent of total billed charges,58% of total billed charges,298.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1245.25,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,1318.5,
NM MUGA,4578481,CDM,341,RC,78481,HCPCS,Outpatient,,,1465,1172,,1245.25,85,,,percent of total billed charges,85% of total billed charges,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,576.87,130,,,fee schedule,Pays 130% Medicare OPPS,298.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,827.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,827.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,827.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,827.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,448.38,102,,,fee schedule,Pays 102% Medicare OPPS,1318.5,90,,,percent of total billed charges,90% of total billed charges,512.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1006.46,68.7,,,percent of total billed charges,68.7% of total billed charges,1172,80,,,percent of total billed charges,80 percent of total billed charges,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,395.63,90,,,fee schedule,Pays 90% Medicare OPPS,849.7,58,,,percent of total billed charges,58% of total billed charges,298.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,443.74,100,,,fee schedule,Pays 100% Medicare OPPS,576.87,130,,,fee schedule,Pays 130% Medicare OPPS,1245.25,85,,,percent of total billed charges,85% of total billed charges,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,298.42,1318.5,
LENS INTRAOCULAR ZMB0020.5,1570705,CDM,276,RC,V2797,HCPCS,Outpatient,,,1485,1188,,1262.25,85,,,percent of total billed charges,85% of total billed charges,371.25,100,,,fee schedule,Pays 100% Medicare OPPS,371.25,100,,,fee schedule,Pays 100% Medicare OPPS,371.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,302.49,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,774.74,52.17,,,case rate,100% of BCBS case rate,774.74,52.17,,,case rate,100% of BCBS case rate,774.74,52.17,,,case rate,100% of BCBS case rate,774.74,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1336.5,90,,,percent of total billed charges,90% of total billed charges,519.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1020.2,68.7,,,percent of total billed charges,68.7% of total billed charges,1188,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1336.5,90,,,fee schedule,Pays 90% Medicare OPPS,861.3,58,,,percent of total billed charges,58% of total billed charges,302.49,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1262.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,302.49,1336.5,
LENS INTRAOCULAR ZMB0020.0,1570706,CDM,276,RC,V2797,HCPCS,Outpatient,,,1485,1188,,1262.25,85,,,percent of total billed charges,85% of total billed charges,371.25,100,,,fee schedule,Pays 100% Medicare OPPS,371.25,100,,,fee schedule,Pays 100% Medicare OPPS,371.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,302.49,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,774.74,52.17,,,case rate,100% of BCBS case rate,774.74,52.17,,,case rate,100% of BCBS case rate,774.74,52.17,,,case rate,100% of BCBS case rate,774.74,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1336.5,90,,,percent of total billed charges,90% of total billed charges,519.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1020.2,68.7,,,percent of total billed charges,68.7% of total billed charges,1188,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1336.5,90,,,fee schedule,Pays 90% Medicare OPPS,861.3,58,,,percent of total billed charges,58% of total billed charges,302.49,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1262.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,302.49,1336.5,
I&D ABSC; COMPL OR MULTI,1510061,CDM,360,RC,10061,HCPCS,Outpatient,,,1500,1200,,1275,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,305.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,316.7,102,,,fee schedule,Pays 102% Medicare OPPS,1350,90,,,percent of total billed charges,90% of total billed charges,525,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1030.5,68.7,,,percent of total billed charges,68.7% of total billed charges,1200,80,,,percent of total billed charges,80 percent of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,279.44,90,,,fee schedule,Pays 90% Medicare OPPS,870,58,,,percent of total billed charges,58% of total billed charges,305.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,328.14,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,1275,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,279.44,1350,
DEB SUBQ TISSUE 20 SQ CM/<,1511042,CDM,360,RC,11042,HCPCS,Outpatient,,,1500,1200,,1275,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,305.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,316.7,102,,,fee schedule,Pays 102% Medicare OPPS,1350,90,,,percent of total billed charges,90% of total billed charges,525,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1030.5,68.7,,,percent of total billed charges,68.7% of total billed charges,1200,80,,,percent of total billed charges,80 percent of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,279.44,90,,,fee schedule,Pays 90% Medicare OPPS,870,58,,,percent of total billed charges,58% of total billed charges,305.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,328.14,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,1275,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,279.44,1350,
IO MAP OF SENT LYMPH NODE,1538900,CDM,360,RC,38900,HCPCS,Outpatient,,,1500,1200,,1275,85,,,percent of total billed charges,85% of total billed charges,375,100,,,fee schedule,Pays 100% Medicare OPPS,375,100,,,fee schedule,Pays 100% Medicare OPPS,375,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,305.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,,,,,other,Not reimbursable per contract,1350,90,,,percent of total billed charges,90% of total billed charges,525,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1030.5,68.7,,,percent of total billed charges,68.7% of total billed charges,1200,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1350,90,,,fee schedule,Pays 90% Medicare OPPS,870,58,,,percent of total billed charges,58% of total billed charges,305.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1275,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,305.55,1350,
CULTURE STOOL BY PCR,3000970,CDM,300,RC,0097U,HCPCS,Outpatient,,,1510,1208,,1283.5,85,,,percent of total billed charges,85% of total billed charges,377.5,100,,,fee schedule,Pays 100% Medicare OPPS,377.5,100,,,fee schedule,Pays 100% Medicare OPPS,377.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,307.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,853.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,853.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,853.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,853.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1359,90,,,percent of total billed charges,90% of total billed charges,528.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1037.37,68.7,,,percent of total billed charges,68.7% of total billed charges,1208,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1359,90,,,fee schedule,Pays 90% Medicare OPPS,875.8,58,,,percent of total billed charges,58% of total billed charges,307.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1283.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,307.59,1359,
FETAL FIBRONECTIN,3082731,CDM,300,RC,82731,HCPCS,Outpatient,,,1510,1208,,1283.5,85,,,percent of total billed charges,85% of total billed charges,64.41,100,,,fee schedule,Pays 100% Medicare OPPS,64.41,100,,,fee schedule,Pays 100% Medicare OPPS,64.41,100,,,fee schedule,Pays 100% Medicare OPPS,83.73,130,,,fee schedule,Pays 130% Medicare OPPS,97.49,120.37,,,fee schedule,120.37% of custom fee schedule,853.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,853.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,853.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,853.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,65.69,102,,,fee schedule,Pays 102% Medicare OPPS,1359,90,,,percent of total billed charges,90% of total billed charges,101.38,125.18,,,fee schedule,125.18% of custom fee schedule,1037.37,68.7,,,percent of total billed charges,68.7% of total billed charges,1208,80,,,percent of total billed charges,80 percent of total billed charges,64.41,100,,,fee schedule,Pays 100% Medicare OPPS,57.96,90,,,fee schedule,Pays 90% Medicare OPPS,875.8,58,,,percent of total billed charges,58% of total billed charges,97.49,120.37,,,fee schedule,120.37% of custom fee schedule,64.41,100,,,fee schedule,Pays 100% Medicare OPPS,83.73,130,,,fee schedule,Pays 130% Medicare OPPS,1283.5,85,,,percent of total billed charges,85% of total billed charges,64.41,100,,,fee schedule,Pays 100% Medicare OPPS,57.96,1359,
3RD HEPATITIS B VIRAL LOAD DNA,3087517,CDM,306,RC,87517,HCPCS,Outpatient,,,1510,1208,,1283.5,85,,,percent of total billed charges,85% of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,130,APC,,fee schedule,Pays 130% Medicare OPPS,64.84,120.37,,,fee schedule,120.37% of custom fee schedule,853.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,853.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,853.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,853.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,43.69,102,,,fee schedule,Pays 102% Medicare OPPS,1359,90,,,percent of total billed charges,90% of total billed charges,67.43,125.18,,,fee schedule,125.18% of custom fee schedule,1037.37,68.7,,,percent of total billed charges,68.7% of total billed charges,1208,80,,,percent of total billed charges,80 percent of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,38.55,90,,,fee schedule,Pays 90% Medicare OPPS,875.8,58,,,percent of total billed charges,58% of total billed charges,64.84,120.37,,,fee schedule,120.37% of custom fee schedule,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,55.69,130,APC,,fee schedule,Pays 130% Medicare OPPS,1283.5,85,,,percent of total billed charges,85% of total billed charges,42.84,100,,,fee schedule,Pays 100% Medicare OPPS,38.55,1359,
.CHROMOSOME BASE (C FG X),3088248,CDM,311,RC,88248,HCPCS,Outpatient,,,1510,1208,,1283.5,85,,,percent of total billed charges,85% of total billed charges,173.17,100,,,fee schedule,Pays 100% Medicare OPPS,173.17,100,,,fee schedule,Pays 100% Medicare OPPS,173.17,100,,,fee schedule,Pays 100% Medicare OPPS,225.12,130,APC,,fee schedule,Pays 130% Medicare OPPS,262.12,120.37,,,fee schedule,120.37% of custom fee schedule,853.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,853.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,853.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,853.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,176.63,102,,,fee schedule,Pays 102% Medicare OPPS,1359,90,,,percent of total billed charges,90% of total billed charges,272.59,125.18,,,fee schedule,125.18% of custom fee schedule,1037.37,68.7,,,percent of total billed charges,68.7% of total billed charges,1208,80,,,percent of total billed charges,80 percent of total billed charges,173.17,100,,,fee schedule,Pays 100% Medicare OPPS,155.85,90,,,fee schedule,Pays 90% Medicare OPPS,875.8,58,,,percent of total billed charges,58% of total billed charges,262.12,120.37,,,fee schedule,120.37% of custom fee schedule,173.17,100,,,fee schedule,Pays 100% Medicare OPPS,225.12,130,APC,,fee schedule,Pays 130% Medicare OPPS,1283.5,85,,,percent of total billed charges,85% of total billed charges,173.17,100,,,fee schedule,Pays 100% Medicare OPPS,155.85,1359,
XR BARIUM ENEMA AIR CON,4074280,CDM,320,RC,74280,HCPCS,Outpatient,,,1510,1208,,1283.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.21,130,,,fee schedule,Pays 130% Medicare OPPS,307.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,853.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,853.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,853.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,848.62,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.67,102,,,fee schedule,Pays 102% Medicare OPPS,1359,90,,,percent of total billed charges,90% of total billed charges,528.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1037.37,68.7,,,percent of total billed charges,68.7% of total billed charges,1208,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,875.8,58,,,percent of total billed charges,58% of total billed charges,307.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.21,130,,,fee schedule,Pays 130% Medicare OPPS,1283.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,1359,
NM I 123 THYROID MULTIDETECT,4578007,CDM,341,RC,78012,HCPCS,Outpatient,,,1510,1208,,1283.5,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,307.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,853.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,853.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,853.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,853.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,345.39,102,,,fee schedule,Pays 102% Medicare OPPS,1359,90,,,percent of total billed charges,90% of total billed charges,528.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1037.37,68.7,,,percent of total billed charges,68.7% of total billed charges,1208,80,,,percent of total billed charges,80 percent of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,304.76,90,,,fee schedule,Pays 90% Medicare OPPS,875.8,58,,,percent of total billed charges,58% of total billed charges,307.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,341.87,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,1283.5,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,304.76,1359,
BLADE KOBYGARD 380-0010,1570771,CDM,272,RC,,,Outpatient,,,1520,1216,,1292,85,,,percent of total billed charges,85% of total billed charges,380,100,,,fee schedule,Pays 100% Medicare OPPS,380,100,,,fee schedule,Pays 100% Medicare OPPS,380,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,309.62,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,858.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,858.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,858.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,858.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1368,90,,,percent of total billed charges,90% of total billed charges,532,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1044.24,68.7,,,percent of total billed charges,68.7% of total billed charges,1216,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1368,90,,,fee schedule,Pays 90% Medicare OPPS,881.6,58,,,percent of total billed charges,58% of total billed charges,309.62,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1292,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,309.62,1368,
SCREW 25MM 3.0 CANNULATED,1570079,CDM,278,RC,C1713,HCPCS,Both,,,1525,1220,,1296.25,85,,,percent of total billed charges,85% of total billed charges,381.25,100,,,fee schedule,Pays 100% Medicare OPPS,381.25,100,,,fee schedule,Pays 100% Medicare OPPS,381.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,310.64,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,795.61,52.17,,,case rate,100% of BCBS case rate,795.61,52.17,,,case rate,100% of BCBS case rate,795.61,52.17,,,case rate,100% of BCBS case rate,795.61,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1372.5,90,,,percent of total billed charges,90% of total billed charges,533.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1047.68,68.7,,,percent of total billed charges,68.7% of total billed charges,1220,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1372.5,90,,,fee schedule,Pays 90% Medicare OPPS,884.5,58,,,percent of total billed charges,58% of total billed charges,310.64,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1296.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,310.64,1372.5,
SCREW SPIN 2MM DIA--14MM LENGTH,1570075,CDM,278,RC,C1713,HCPCS,Both,,,1535,1228,,1304.75,85,,,percent of total billed charges,85% of total billed charges,383.75,100,,,fee schedule,Pays 100% Medicare OPPS,383.75,100,,,fee schedule,Pays 100% Medicare OPPS,383.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,312.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,800.82,52.17,,,case rate,100% of BCBS case rate,800.82,52.17,,,case rate,100% of BCBS case rate,800.82,52.17,,,case rate,100% of BCBS case rate,800.82,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1381.5,90,,,percent of total billed charges,90% of total billed charges,537.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1054.55,68.7,,,percent of total billed charges,68.7% of total billed charges,1228,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1381.5,90,,,fee schedule,Pays 90% Medicare OPPS,890.3,58,,,percent of total billed charges,58% of total billed charges,312.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1304.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,312.68,1381.5,
SCREW QWIX FIXATION 3.0MM X 26MM,1570078,CDM,278,RC,C1713,HCPCS,Both,,,1535,1228,,1304.75,85,,,percent of total billed charges,85% of total billed charges,383.75,100,,,fee schedule,Pays 100% Medicare OPPS,383.75,100,,,fee schedule,Pays 100% Medicare OPPS,383.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,312.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,800.82,52.17,,,case rate,100% of BCBS case rate,800.82,52.17,,,case rate,100% of BCBS case rate,800.82,52.17,,,case rate,100% of BCBS case rate,800.82,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1381.5,90,,,percent of total billed charges,90% of total billed charges,537.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1054.55,68.7,,,percent of total billed charges,68.7% of total billed charges,1228,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1381.5,90,,,fee schedule,Pays 90% Medicare OPPS,890.3,58,,,percent of total billed charges,58% of total billed charges,312.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1304.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,312.68,1381.5,
US BILAT ARTERIAL LOW EX,4600015,CDM,921,RC,93925,HCPCS,Outpatient,,,1545,1236,,1313.25,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,314.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,872.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,872.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,872.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,872.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,1390.5,90,,,percent of total billed charges,90% of total billed charges,540.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1061.42,68.7,,,percent of total billed charges,68.7% of total billed charges,1236,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,896.1,58,,,percent of total billed charges,58% of total billed charges,314.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1313.25,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,1390.5,
US UPPER ARTERIAL-BIL,4693930,CDM,921,RC,93930,HCPCS,Outpatient,,,1545,1236,,1313.25,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,314.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,872.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,872.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,872.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,872.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,1390.5,90,,,percent of total billed charges,90% of total billed charges,540.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1061.42,68.7,,,percent of total billed charges,68.7% of total billed charges,1236,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,896.1,58,,,percent of total billed charges,58% of total billed charges,314.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1313.25,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,1390.5,
CASIRIVI AND IMDEV INFUSION,2610243,CDM,761,RC,M0243,HCPCS,Outpatient,,,1550,1240,,1317.5,85,,,percent of total billed charges,85% of total billed charges,396.25,100,,,fee schedule,Pays 100% Medicare OPPS,396.25,100,,,fee schedule,Pays 100% Medicare OPPS,396.25,100,,,fee schedule,Pays 100% Medicare OPPS,515.12,130,,,fee schedule,Pays 130% Medicare OPPS,315.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,875.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,875.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,875.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,875.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,404.17,102,,,fee schedule,Pays 102% Medicare OPPS,1395,90,,,percent of total billed charges,90% of total billed charges,542.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1064.85,68.7,,,percent of total billed charges,68.7% of total billed charges,1240,80,,,percent of total billed charges,80 percent of total billed charges,396.25,100,,,fee schedule,Pays 100% Medicare OPPS,356.62,90,,,fee schedule,Pays 90% Medicare OPPS,899,58,,,percent of total billed charges,58% of total billed charges,315.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,396.25,100,,,fee schedule,Pays 100% Medicare OPPS,515.12,130,,,fee schedule,Pays 130% Medicare OPPS,1317.5,85,,,percent of total billed charges,85% of total billed charges,396.25,100,,,fee schedule,Pays 100% Medicare OPPS,315.74,1395,
CASIRIVI AND IMDEV INFUSION,2610244,CDM,450,RC,M0243,HCPCS,Outpatient,,,1550,1240,,1317.5,85,,,percent of total billed charges,85% of total billed charges,396.25,100,,,fee schedule,Pays 100% Medicare OPPS,396.25,100,,,fee schedule,Pays 100% Medicare OPPS,396.25,100,,,fee schedule,Pays 100% Medicare OPPS,515.12,130,,,fee schedule,Pays 130% Medicare OPPS,315.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,875.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,875.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,875.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,875.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,404.17,102,,,fee schedule,Pays 102% Medicare OPPS,1395,90,,,percent of total billed charges,90% of total billed charges,542.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1064.85,68.7,,,percent of total billed charges,68.7% of total billed charges,1240,80,,,percent of total billed charges,80 percent of total billed charges,396.25,100,,,fee schedule,Pays 100% Medicare OPPS,356.62,90,,,fee schedule,Pays 90% Medicare OPPS,899,58,,,percent of total billed charges,58% of total billed charges,315.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,396.25,100,,,fee schedule,Pays 100% Medicare OPPS,515.12,130,,,fee schedule,Pays 130% Medicare OPPS,1317.5,85,,,percent of total billed charges,85% of total billed charges,396.25,100,,,fee schedule,Pays 100% Medicare OPPS,315.74,1395,
SOTROVIMAB INFUSION,2610247,CDM,761,RC,M0247,HCPCS,Outpatient,,,1550,1240,,1317.5,85,,,percent of total billed charges,85% of total billed charges,396.25,100,,,fee schedule,Pays 100% Medicare OPPS,396.25,100,,,fee schedule,Pays 100% Medicare OPPS,396.25,100,,,fee schedule,Pays 100% Medicare OPPS,515.12,130,,,fee schedule,Pays 130% Medicare OPPS,315.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,875.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,875.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,875.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,875.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,404.17,102,,,fee schedule,Pays 102% Medicare OPPS,1395,90,,,percent of total billed charges,90% of total billed charges,542.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1064.85,68.7,,,percent of total billed charges,68.7% of total billed charges,1240,80,,,percent of total billed charges,80 percent of total billed charges,396.25,100,,,fee schedule,Pays 100% Medicare OPPS,356.62,90,,,fee schedule,Pays 90% Medicare OPPS,899,58,,,percent of total billed charges,58% of total billed charges,315.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,396.25,100,,,fee schedule,Pays 100% Medicare OPPS,515.12,130,,,fee schedule,Pays 130% Medicare OPPS,1317.5,85,,,percent of total billed charges,85% of total billed charges,396.25,100,,,fee schedule,Pays 100% Medicare OPPS,315.74,1395,
SOTROVIMAB INFUSION ER,2610248,CDM,450,RC,M0247,HCPCS,Outpatient,,,1550,1240,,1317.5,85,,,percent of total billed charges,85% of total billed charges,396.25,100,,,fee schedule,Pays 100% Medicare OPPS,396.25,100,,,fee schedule,Pays 100% Medicare OPPS,396.25,100,,,fee schedule,Pays 100% Medicare OPPS,515.12,130,,,fee schedule,Pays 130% Medicare OPPS,315.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,875.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,875.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,875.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,875.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,404.17,102,,,fee schedule,Pays 102% Medicare OPPS,1395,90,,,percent of total billed charges,90% of total billed charges,542.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1064.85,68.7,,,percent of total billed charges,68.7% of total billed charges,1240,80,,,percent of total billed charges,80 percent of total billed charges,396.25,100,,,fee schedule,Pays 100% Medicare OPPS,356.62,90,,,fee schedule,Pays 90% Medicare OPPS,899,58,,,percent of total billed charges,58% of total billed charges,315.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,396.25,100,,,fee schedule,Pays 100% Medicare OPPS,515.12,130,,,fee schedule,Pays 130% Medicare OPPS,1317.5,85,,,percent of total billed charges,85% of total billed charges,396.25,100,,,fee schedule,Pays 100% Medicare OPPS,315.74,1395,
US ARTERIAL LOWER EXT/BIL,4693925,CDM,921,RC,93925,HCPCS,Outpatient,,,1550,1240,,1317.5,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,315.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,875.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,875.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,875.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,875.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,1395,90,,,percent of total billed charges,90% of total billed charges,542.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1064.85,68.7,,,percent of total billed charges,68.7% of total billed charges,1240,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,899,58,,,percent of total billed charges,58% of total billed charges,315.74,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1317.5,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,1395,
"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities",2025270,CDM,450,RC,12001,HCPCS,Outpatient,,,1560,1248,,1326,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,317.77,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,881.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,881.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,881.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,881.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,164.54,102,,,fee schedule,Pays 102% Medicare OPPS,1404,90,,,percent of total billed charges,90% of total billed charges,546,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1071.72,68.7,,,percent of total billed charges,68.7% of total billed charges,1248,80,,,percent of total billed charges,80 percent of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,145.18,90,,,fee schedule,Pays 90% Medicare OPPS,904.8,58,,,percent of total billed charges,58% of total billed charges,317.77,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.83,100,,,fee schedule,Pays 100% Medicare OPPS,206.48,130,,,fee schedule,Pays 130% Medicare OPPS,1326,85,,,percent of total billed charges,85% of total billed charges,161.31,100,,,fee schedule,Pays 100% Medicare OPPS,145.18,1404,
HERNIA SURGIMESH WN T1015,1570052,CDM,278,RC,C1781,HCPCS,Both,,,1575,1260,,1338.75,85,,,percent of total billed charges,85% of total billed charges,393.75,100,,,fee schedule,Pays 100% Medicare OPPS,393.75,100,,,fee schedule,Pays 100% Medicare OPPS,393.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,320.83,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,821.69,52.17,,,case rate,100% of BCBS case rate,821.69,52.17,,,case rate,100% of BCBS case rate,821.69,52.17,,,case rate,100% of BCBS case rate,821.69,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1417.5,90,,,percent of total billed charges,90% of total billed charges,551.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1082.03,68.7,,,percent of total billed charges,68.7% of total billed charges,1260,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1417.5,90,,,fee schedule,Pays 90% Medicare OPPS,913.5,58,,,percent of total billed charges,58% of total billed charges,320.83,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1338.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,320.83,1417.5,
Scan using a radioactive medication (radiopharmaceutical) to take pictures or images of the thyroid gland.,4578014,CDM,341,RC,78014,HCPCS,Outpatient,,,1575,1260,,1338.75,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,320.83,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,889.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,889.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,889.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,889.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,345.39,102,,,fee schedule,Pays 102% Medicare OPPS,1417.5,90,,,percent of total billed charges,90% of total billed charges,551.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1082.03,68.7,,,percent of total billed charges,68.7% of total billed charges,1260,80,,,percent of total billed charges,80 percent of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,304.76,90,,,fee schedule,Pays 90% Medicare OPPS,913.5,58,,,percent of total billed charges,58% of total billed charges,320.83,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,341.87,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,1338.75,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,304.76,1417.5,
STAPLER TA TA6035S,7950298,CDM,272,RC,,,Outpatient,,,1585,1268,,1347.25,85,,,percent of total billed charges,85% of total billed charges,396.25,100,,,fee schedule,Pays 100% Medicare OPPS,396.25,100,,,fee schedule,Pays 100% Medicare OPPS,396.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,322.86,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,895.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,895.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,895.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,895.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1426.5,90,,,percent of total billed charges,90% of total billed charges,554.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1088.9,68.7,,,percent of total billed charges,68.7% of total billed charges,1268,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1426.5,90,,,fee schedule,Pays 90% Medicare OPPS,919.3,58,,,percent of total billed charges,58% of total billed charges,322.86,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1347.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,322.86,1426.5,
"3RD METANEPHRINES,PLASMA",3000196,CDM,301,RC,83835,HCPCS,Outpatient,,,1590,1272,,1351.5,85,,,percent of total billed charges,85% of total billed charges,16.94,100,,,fee schedule,Pays 100% Medicare OPPS,16.94,100,,,fee schedule,Pays 100% Medicare OPPS,16.94,100,,,fee schedule,Pays 100% Medicare OPPS,22.02,130,APC,,fee schedule,Pays 130% Medicare OPPS,25.64,120.37,,,fee schedule,120.37% of custom fee schedule,898.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,898.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,898.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,898.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,17.27,102,,,fee schedule,Pays 102% Medicare OPPS,1431,90,,,percent of total billed charges,90% of total billed charges,26.66,125.18,,,fee schedule,125.18% of custom fee schedule,1092.33,68.7,,,percent of total billed charges,68.7% of total billed charges,1272,80,,,percent of total billed charges,80 percent of total billed charges,16.94,100,,,fee schedule,Pays 100% Medicare OPPS,15.24,90,,,fee schedule,Pays 90% Medicare OPPS,922.2,58,,,percent of total billed charges,58% of total billed charges,25.64,120.37,,,fee schedule,120.37% of custom fee schedule,16.94,100,,,fee schedule,Pays 100% Medicare OPPS,22.02,130,APC,,fee schedule,Pays 130% Medicare OPPS,1351.5,85,,,percent of total billed charges,85% of total billed charges,16.94,100,,,fee schedule,Pays 100% Medicare OPPS,15.24,1431,
LINEAR CUTTER POWERED ECHELON PLEE60A,7950284,CDM,272,RC,,,Outpatient,,,1590,1272,,1351.5,85,,,percent of total billed charges,85% of total billed charges,397.5,100,,,fee schedule,Pays 100% Medicare OPPS,397.5,100,,,fee schedule,Pays 100% Medicare OPPS,397.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,323.88,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,898.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,898.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,898.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,898.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1431,90,,,percent of total billed charges,90% of total billed charges,556.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1092.33,68.7,,,percent of total billed charges,68.7% of total billed charges,1272,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1431,90,,,fee schedule,Pays 90% Medicare OPPS,922.2,58,,,percent of total billed charges,58% of total billed charges,323.88,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1351.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,323.88,1431,
US DUP AORTA/IVC/COMPLET,4693978,CDM,921,RC,93978,HCPCS,Outpatient,,,1595,1276,,1355.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,324.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,901.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,901.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,901.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,901.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,1435.5,90,,,percent of total billed charges,90% of total billed charges,558.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1095.77,68.7,,,percent of total billed charges,68.7% of total billed charges,1276,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,925.1,58,,,percent of total billed charges,58% of total billed charges,324.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1355.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,1435.5,
XR MYELO CERVICAL,4072240,CDM,320,RC,72240,HCPCS,Outpatient,,,1615,1292,,1372.75,85,,,percent of total billed charges,85% of total billed charges,642.68,100,,,fee schedule,Pays 100% Medicare OPPS,642.68,100,,,fee schedule,Pays 100% Medicare OPPS,642.68,100,,,fee schedule,Pays 100% Medicare OPPS,847.01,130,,,fee schedule,Pays 130% Medicare OPPS,328.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,912.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,912.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,912.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,907.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,655.53,102,,,fee schedule,Pays 102% Medicare OPPS,1453.5,90,,,percent of total billed charges,90% of total billed charges,565.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1109.51,68.7,,,percent of total billed charges,68.7% of total billed charges,1292,80,,,percent of total billed charges,80 percent of total billed charges,642.68,100,,,fee schedule,Pays 100% Medicare OPPS,578.41,90,,,fee schedule,Pays 90% Medicare OPPS,936.7,58,,,percent of total billed charges,58% of total billed charges,328.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,651.54,100,,,fee schedule,Pays 100% Medicare OPPS,847.01,130,,,fee schedule,Pays 130% Medicare OPPS,1372.75,85,,,percent of total billed charges,85% of total billed charges,642.68,100,,,fee schedule,Pays 100% Medicare OPPS,328.98,1453.5,
XR MYELO THORACIC,4072255,CDM,320,RC,72255,HCPCS,Outpatient,,,1615,1292,,1372.75,85,,,percent of total billed charges,85% of total billed charges,642.68,100,,,fee schedule,Pays 100% Medicare OPPS,642.68,100,,,fee schedule,Pays 100% Medicare OPPS,642.68,100,,,fee schedule,Pays 100% Medicare OPPS,847.01,130,,,fee schedule,Pays 130% Medicare OPPS,328.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,912.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,912.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,912.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,907.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,655.53,102,,,fee schedule,Pays 102% Medicare OPPS,1453.5,90,,,percent of total billed charges,90% of total billed charges,565.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1109.51,68.7,,,percent of total billed charges,68.7% of total billed charges,1292,80,,,percent of total billed charges,80 percent of total billed charges,642.68,100,,,fee schedule,Pays 100% Medicare OPPS,578.41,90,,,fee schedule,Pays 90% Medicare OPPS,936.7,58,,,percent of total billed charges,58% of total billed charges,328.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,651.54,100,,,fee schedule,Pays 100% Medicare OPPS,847.01,130,,,fee schedule,Pays 130% Medicare OPPS,1372.75,85,,,percent of total billed charges,85% of total billed charges,642.68,100,,,fee schedule,Pays 100% Medicare OPPS,328.98,1453.5,
XR MYELO LUMBAR,4072265,CDM,320,RC,72265,HCPCS,Outpatient,,,1615,1292,,1372.75,85,,,percent of total billed charges,85% of total billed charges,642.68,100,,,fee schedule,Pays 100% Medicare OPPS,642.68,100,,,fee schedule,Pays 100% Medicare OPPS,642.68,100,,,fee schedule,Pays 100% Medicare OPPS,847.01,130,,,fee schedule,Pays 130% Medicare OPPS,328.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,912.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,912.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,912.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,907.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,655.53,102,,,fee schedule,Pays 102% Medicare OPPS,1453.5,90,,,percent of total billed charges,90% of total billed charges,565.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1109.51,68.7,,,percent of total billed charges,68.7% of total billed charges,1292,80,,,percent of total billed charges,80 percent of total billed charges,642.68,100,,,fee schedule,Pays 100% Medicare OPPS,578.41,90,,,fee schedule,Pays 90% Medicare OPPS,936.7,58,,,percent of total billed charges,58% of total billed charges,328.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,651.54,100,,,fee schedule,Pays 100% Medicare OPPS,847.01,130,,,fee schedule,Pays 130% Medicare OPPS,1372.75,85,,,percent of total billed charges,85% of total billed charges,642.68,100,,,fee schedule,Pays 100% Medicare OPPS,328.98,1453.5,
XR GI BARIUM SWALLOW,4074246,CDM,320,RC,74220,HCPCS,Outpatient,,,1625,1300,,1381.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.21,130,,,fee schedule,Pays 130% Medicare OPPS,331.01,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,918.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,918.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,918.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,913.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.67,102,,,fee schedule,Pays 102% Medicare OPPS,1462.5,90,,,percent of total billed charges,90% of total billed charges,568.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1116.38,68.7,,,percent of total billed charges,68.7% of total billed charges,1300,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,942.5,58,,,percent of total billed charges,58% of total billed charges,331.01,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.21,130,,,fee schedule,Pays 130% Medicare OPPS,1381.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,1462.5,
FORCEP BIPOLAR CUTTING,7950112,CDM,272,RC,,,Outpatient,,,1640,1312,,1394,85,,,percent of total billed charges,85% of total billed charges,410,100,,,fee schedule,Pays 100% Medicare OPPS,410,100,,,fee schedule,Pays 100% Medicare OPPS,410,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,334.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,926.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,926.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,926.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,926.6,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1476,90,,,percent of total billed charges,90% of total billed charges,574,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1126.68,68.7,,,percent of total billed charges,68.7% of total billed charges,1312,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1476,90,,,fee schedule,Pays 90% Medicare OPPS,951.2,58,,,percent of total billed charges,58% of total billed charges,334.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1394,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,334.07,1476,
STAPLER CONTOUR CURVED CUTTER CS40B,7950280,CDM,272,RC,,,Outpatient,,,1650,1320,,1402.5,85,,,percent of total billed charges,85% of total billed charges,412.5,100,,,fee schedule,Pays 100% Medicare OPPS,412.5,100,,,fee schedule,Pays 100% Medicare OPPS,412.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,336.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,932.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,932.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,932.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,932.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1485,90,,,percent of total billed charges,90% of total billed charges,577.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1133.55,68.7,,,percent of total billed charges,68.7% of total billed charges,1320,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1485,90,,,fee schedule,Pays 90% Medicare OPPS,957,58,,,percent of total billed charges,58% of total billed charges,336.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1402.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,336.11,1485,
STAPLER CONTOUR CURVED CUTTER CS40G,7950281,CDM,272,RC,,,Outpatient,,,1650,1320,,1402.5,85,,,percent of total billed charges,85% of total billed charges,412.5,100,,,fee schedule,Pays 100% Medicare OPPS,412.5,100,,,fee schedule,Pays 100% Medicare OPPS,412.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,336.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,932.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,932.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,932.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,932.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1485,90,,,percent of total billed charges,90% of total billed charges,577.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1133.55,68.7,,,percent of total billed charges,68.7% of total billed charges,1320,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1485,90,,,fee schedule,Pays 90% Medicare OPPS,957,58,,,percent of total billed charges,58% of total billed charges,336.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1402.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,336.11,1485,
STAPLER CIRCULAR HEMORRHOIDAL PPH03,7950123,CDM,272,RC,,,Outpatient,,,1670,1336,,1419.5,85,,,percent of total billed charges,85% of total billed charges,417.5,100,,,fee schedule,Pays 100% Medicare OPPS,417.5,100,,,fee schedule,Pays 100% Medicare OPPS,417.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,340.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,943.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,943.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,943.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,943.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1503,90,,,percent of total billed charges,90% of total billed charges,584.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1147.29,68.7,,,percent of total billed charges,68.7% of total billed charges,1336,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1503,90,,,fee schedule,Pays 90% Medicare OPPS,968.6,58,,,percent of total billed charges,58% of total billed charges,340.18,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1419.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,340.18,1503,
HERNIA PATCH PROCEED VENTRAL PVPS,1570053,CDM,278,RC,C1781,HCPCS,Both,,,1675,1340,,1423.75,85,,,percent of total billed charges,85% of total billed charges,418.75,100,,,fee schedule,Pays 100% Medicare OPPS,418.75,100,,,fee schedule,Pays 100% Medicare OPPS,418.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,341.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,873.86,52.17,,,case rate,100% of BCBS case rate,873.86,52.17,,,case rate,100% of BCBS case rate,873.86,52.17,,,case rate,100% of BCBS case rate,873.86,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1507.5,90,,,percent of total billed charges,90% of total billed charges,586.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1150.73,68.7,,,percent of total billed charges,68.7% of total billed charges,1340,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1507.5,90,,,fee schedule,Pays 90% Medicare OPPS,971.5,58,,,percent of total billed charges,58% of total billed charges,341.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1423.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,341.2,1507.5,
Complete bilateral study of the extremities,4600018,CDM,921,RC,93970,HCPCS,Outpatient,,,1690,1352,,1436.5,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,344.25,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,954.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,954.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,954.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,954.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,1521,90,,,percent of total billed charges,90% of total billed charges,591.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1161.03,68.7,,,percent of total billed charges,68.7% of total billed charges,1352,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,980.2,58,,,percent of total billed charges,58% of total billed charges,344.25,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1436.5,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,1521,
Complete bilateral study of the extremities,4600019,CDM,921,RC,93970,HCPCS,Outpatient,,,1690,1352,,1436.5,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,344.25,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,954.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,954.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,954.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,954.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,1521,90,,,percent of total billed charges,90% of total billed charges,591.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1161.03,68.7,,,percent of total billed charges,68.7% of total billed charges,1352,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,980.2,58,,,percent of total billed charges,58% of total billed charges,344.25,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1436.5,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,1521,
Complete bilateral study of the extremities,4693970,CDM,921,RC,93970,HCPCS,Outpatient,,,1690,1352,,1436.5,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,344.25,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,954.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,954.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,954.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,954.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,1521,90,,,percent of total billed charges,90% of total billed charges,591.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1161.03,68.7,,,percent of total billed charges,68.7% of total billed charges,1352,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,980.2,58,,,percent of total billed charges,58% of total billed charges,344.25,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1436.5,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,1521,
DREAMTOME RX 44 260CM,1750026,CDM,272,RC,,,Outpatient,,,1695,1356,,1440.75,85,,,percent of total billed charges,85% of total billed charges,423.75,100,,,fee schedule,Pays 100% Medicare OPPS,423.75,100,,,fee schedule,Pays 100% Medicare OPPS,423.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,345.27,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,957.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,957.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,957.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,957.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1525.5,90,,,percent of total billed charges,90% of total billed charges,593.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1164.47,68.7,,,percent of total billed charges,68.7% of total billed charges,1356,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1525.5,90,,,fee schedule,Pays 90% Medicare OPPS,983.1,58,,,percent of total billed charges,58% of total billed charges,345.27,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1440.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,345.27,1525.5,
DREAMTOME RX 44 450CM,1750059,CDM,272,RC,,,Outpatient,,,1695,1356,,1440.75,85,,,percent of total billed charges,85% of total billed charges,423.75,100,,,fee schedule,Pays 100% Medicare OPPS,423.75,100,,,fee schedule,Pays 100% Medicare OPPS,423.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,345.27,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,957.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,957.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,957.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,957.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1525.5,90,,,percent of total billed charges,90% of total billed charges,593.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1164.47,68.7,,,percent of total billed charges,68.7% of total billed charges,1356,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1525.5,90,,,fee schedule,Pays 90% Medicare OPPS,983.1,58,,,percent of total billed charges,58% of total billed charges,345.27,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1440.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,345.27,1525.5,
DRILL BIT 3.0 CANNULATED TWIST,1570347,CDM,278,RC,A4649,HCPCS,Both,,,1700,1360,,1445,85,,,percent of total billed charges,85% of total billed charges,425,100,,,fee schedule,Pays 100% Medicare OPPS,425,100,,,fee schedule,Pays 100% Medicare OPPS,425,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,346.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,886.91,52.17,,,case rate,100% of BCBS case rate,886.91,52.17,,,case rate,100% of BCBS case rate,886.91,52.17,,,case rate,100% of BCBS case rate,886.91,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1530,90,,,percent of total billed charges,90% of total billed charges,595,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1167.9,68.7,,,percent of total billed charges,68.7% of total billed charges,1360,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1530,90,,,fee schedule,Pays 90% Medicare OPPS,986,58,,,percent of total billed charges,58% of total billed charges,346.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1445,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,346.29,1530,
ANCHORS BONE 3 W ARTHRO DEL SYS ADVNCD,1570864,CDM,278,RC,29827,HCPCS,Both,,,1700,1360,,1445,85,,,percent of total billed charges,85% of total billed charges,5626.71,100,,,fee schedule,Pays 100% Medicare OPPS,5626.71,100,,,fee schedule,Pays 100% Medicare OPPS,5626.71,100,,,fee schedule,Pays 100% Medicare OPPS,7563.51,130,,,fee schedule,Pays 130% Medicare OPPS,346.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,886.91,52.17,,,case rate,100% of BCBS case rate,886.91,52.17,,,case rate,100% of BCBS case rate,886.91,52.17,,,case rate,100% of BCBS case rate,886.91,52.17,,,case rate,100% of BCBS case rate,5739.25,102,,,fee schedule,Pays 102% Medicare OPPS,1530,90,,,percent of total billed charges,90% of total billed charges,595,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1167.9,68.7,,,percent of total billed charges,68.7% of total billed charges,1360,80,,,percent of total billed charges,80 percent of total billed charges,5626.71,100,,,fee schedule,Pays 100% Medicare OPPS,5064.04,90,,,fee schedule,Pays 90% Medicare OPPS,986,58,,,percent of total billed charges,58% of total billed charges,346.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5818.09,100,,,fee schedule,Pays 100% Medicare OPPS,7563.51,130,,,fee schedule,Pays 130% Medicare OPPS,1445,85,,,percent of total billed charges,85% of total billed charges,5626.71,100,,,fee schedule,Pays 100% Medicare OPPS,346.29,7563.51,
"Emergency department visit, problem with significant threat to life or function",2099285,CDM,450,RC,99285,HCPCS,Outpatient,,,1700,1360,,1445,85,,,percent of total billed charges,85% of total billed charges,469.05,100,,,fee schedule,Pays 100% Medicare OPPS,469.05,100,,,fee schedule,Pays 100% Medicare OPPS,469.05,100,,,fee schedule,Pays 100% Medicare OPPS,626.73,130,,,fee schedule,Pays 130% Medicare OPPS,346.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1700,100,,,percent of total billed charges,671 dollar flat fee for ER,1700,100,,,percent of total billed charges,671 dollar flat fee for ER,1700,100,,,percent of total billed charges,671 dollar flat fee for ER,1700,100,,,percent of total billed charges,671 dollar flat fee for ER,478.43,102,,,fee schedule,Pays 102% Medicare OPPS,1530,90,,,percent of total billed charges,90% of total billed charges,595,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1167.9,68.7,,,percent of total billed charges,68.7% of total billed charges,1360,80,,,percent of total billed charges,80 percent of total billed charges,469.05,100,,,fee schedule,Pays 100% Medicare OPPS,422.14,90,,,fee schedule,Pays 90% Medicare OPPS,986,58,,,percent of total billed charges,58% of total billed charges,346.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,482.1,100,,,fee schedule,Pays 100% Medicare OPPS,626.73,130,,,fee schedule,Pays 130% Medicare OPPS,1445,85,,,percent of total billed charges,85% of total billed charges,469.05,100,,,fee schedule,Pays 100% Medicare OPPS,346.29,1700,
NM RENAL SCAN,4578707,CDM,341,RC,78707,HCPCS,Outpatient,,,1700,1360,,1445,85,,,percent of total billed charges,85% of total billed charges,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,576.87,130,,,fee schedule,Pays 130% Medicare OPPS,346.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,960.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,960.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,960.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,960.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,448.38,102,,,fee schedule,Pays 102% Medicare OPPS,1530,90,,,percent of total billed charges,90% of total billed charges,595,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1167.9,68.7,,,percent of total billed charges,68.7% of total billed charges,1360,80,,,percent of total billed charges,80 percent of total billed charges,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,395.63,90,,,fee schedule,Pays 90% Medicare OPPS,986,58,,,percent of total billed charges,58% of total billed charges,346.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,443.74,100,,,fee schedule,Pays 100% Medicare OPPS,576.87,130,,,fee schedule,Pays 130% Medicare OPPS,1445,85,,,percent of total billed charges,85% of total billed charges,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,346.29,1530,
SB BLOOD ADMINISTRATION,3136430,CDM,761,RC,36430,HCPCS,Outpatient,,,1710,1368,,1453.5,85,,,percent of total billed charges,85% of total billed charges,356.55,100,,,fee schedule,Pays 100% Medicare OPPS,356.55,100,,,fee schedule,Pays 100% Medicare OPPS,356.55,100,,,fee schedule,Pays 100% Medicare OPPS,466.23,130,,,fee schedule,Pays 130% Medicare OPPS,348.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,966.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,966.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,966.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,966.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,363.68,102,,,fee schedule,Pays 102% Medicare OPPS,1539,90,,,percent of total billed charges,90% of total billed charges,598.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1174.77,68.7,,,percent of total billed charges,68.7% of total billed charges,1368,80,,,percent of total billed charges,80 percent of total billed charges,356.55,100,,,fee schedule,Pays 100% Medicare OPPS,320.89,90,,,fee schedule,Pays 90% Medicare OPPS,991.8,58,,,percent of total billed charges,58% of total billed charges,348.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,358.64,100,,,fee schedule,Pays 100% Medicare OPPS,466.23,130,,,fee schedule,Pays 130% Medicare OPPS,1453.5,85,,,percent of total billed charges,85% of total billed charges,356.55,100,,,fee schedule,Pays 100% Medicare OPPS,320.89,1539,
LENS INTRAOCULAR RESTOR SN6AD1 13.5,1570220,CDM,276,RC,V2797,HCPCS,Outpatient,,,1735,1388,,1474.75,85,,,percent of total billed charges,85% of total billed charges,433.75,100,,,fee schedule,Pays 100% Medicare OPPS,433.75,100,,,fee schedule,Pays 100% Medicare OPPS,433.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,353.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,905.17,52.17,,,case rate,100% of BCBS case rate,905.17,52.17,,,case rate,100% of BCBS case rate,905.17,52.17,,,case rate,100% of BCBS case rate,905.17,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1561.5,90,,,percent of total billed charges,90% of total billed charges,607.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1191.95,68.7,,,percent of total billed charges,68.7% of total billed charges,1388,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1561.5,90,,,fee schedule,Pays 90% Medicare OPPS,1006.3,58,,,percent of total billed charges,58% of total billed charges,353.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1474.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,353.42,1561.5,
SINUS GUIDE CATHETER F-70C,1570751,CDM,272,RC,,,Outpatient,,,1740,1392,,1479,85,,,percent of total billed charges,85% of total billed charges,435,100,,,fee schedule,Pays 100% Medicare OPPS,435,100,,,fee schedule,Pays 100% Medicare OPPS,435,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,354.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,983.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,983.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,983.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,983.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1566,90,,,percent of total billed charges,90% of total billed charges,609,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1195.38,68.7,,,percent of total billed charges,68.7% of total billed charges,1392,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1566,90,,,fee schedule,Pays 90% Medicare OPPS,1009.2,58,,,percent of total billed charges,58% of total billed charges,354.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1479,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,354.44,1566,
SINUS GUIDE CATHETER M-110,1570752,CDM,272,RC,,,Outpatient,,,1740,1392,,1479,85,,,percent of total billed charges,85% of total billed charges,435,100,,,fee schedule,Pays 100% Medicare OPPS,435,100,,,fee schedule,Pays 100% Medicare OPPS,435,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,354.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,983.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,983.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,983.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,983.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1566,90,,,percent of total billed charges,90% of total billed charges,609,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1195.38,68.7,,,percent of total billed charges,68.7% of total billed charges,1392,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1566,90,,,fee schedule,Pays 90% Medicare OPPS,1009.2,58,,,percent of total billed charges,58% of total billed charges,354.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1479,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,354.44,1566,
HEMORRHOIDECTOMY,1746083,CDM,360,RC,,,Outpatient,,,1740,1392,,1479,85,,,percent of total billed charges,85% of total billed charges,435,100,,,fee schedule,Pays 100% Medicare OPPS,435,100,,,fee schedule,Pays 100% Medicare OPPS,435,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,354.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,983.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,983.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,983.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,983.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1566,90,,,percent of total billed charges,90% of total billed charges,609,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1195.38,68.7,,,percent of total billed charges,68.7% of total billed charges,1392,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1566,90,,,fee schedule,Pays 90% Medicare OPPS,1009.2,58,,,percent of total billed charges,58% of total billed charges,354.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1479,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,354.44,1566,
EXCISION ANUS SKIN TAG,1746230,CDM,360,RC,,,Outpatient,,,1740,1392,,1479,85,,,percent of total billed charges,85% of total billed charges,435,100,,,fee schedule,Pays 100% Medicare OPPS,435,100,,,fee schedule,Pays 100% Medicare OPPS,435,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,354.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,983.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,983.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,983.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,983.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1566,90,,,percent of total billed charges,90% of total billed charges,609,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1195.38,68.7,,,percent of total billed charges,68.7% of total billed charges,1392,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1566,90,,,fee schedule,Pays 90% Medicare OPPS,1009.2,58,,,percent of total billed charges,58% of total billed charges,354.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1479,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,354.44,1566,
DRAIN EXTERNAL EAR LESION,2069000,CDM,450,RC,69000,HCPCS,Outpatient,,,1750,1400,,1487.5,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,742.06,130,,,fee schedule,Pays 130% Medicare OPPS,356.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,988.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,988.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,988.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,988.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,570.17,102,,,fee schedule,Pays 102% Medicare OPPS,1575,90,,,percent of total billed charges,90% of total billed charges,612.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1202.25,68.7,,,percent of total billed charges,68.7% of total billed charges,1400,80,,,percent of total billed charges,80 percent of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,503.1,90,,,fee schedule,Pays 90% Medicare OPPS,1015,58,,,percent of total billed charges,58% of total billed charges,356.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,570.82,100,,,fee schedule,Pays 100% Medicare OPPS,742.06,130,,,fee schedule,Pays 130% Medicare OPPS,1487.5,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,356.48,1575,
STAPLER CIRCULAR CURVED 29mm,7950122,CDM,270,RC,,,Outpatient,,,1750,1400,,1487.5,85,,,percent of total billed charges,85% of total billed charges,437.5,100,,,fee schedule,Pays 100% Medicare OPPS,437.5,100,,,fee schedule,Pays 100% Medicare OPPS,437.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,356.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,988.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,988.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,988.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,988.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1575,90,,,percent of total billed charges,90% of total billed charges,612.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1202.25,68.7,,,percent of total billed charges,68.7% of total billed charges,1400,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1575,90,,,fee schedule,Pays 90% Medicare OPPS,1015,58,,,percent of total billed charges,58% of total billed charges,356.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1487.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,356.48,1575,
ENDOSCOPIC STAPLER,7950124,CDM,270,RC,,,Outpatient,,,1775,1420,,1508.75,85,,,percent of total billed charges,85% of total billed charges,443.75,100,,,fee schedule,Pays 100% Medicare OPPS,443.75,100,,,fee schedule,Pays 100% Medicare OPPS,443.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,361.57,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1002.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1002.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1002.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1002.88,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1597.5,90,,,percent of total billed charges,90% of total billed charges,621.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1219.43,68.7,,,percent of total billed charges,68.7% of total billed charges,1420,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1597.5,90,,,fee schedule,Pays 90% Medicare OPPS,1029.5,58,,,percent of total billed charges,58% of total billed charges,361.57,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1508.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,361.57,1597.5,
EXCISION BENIGN LESION INCL MARGINS,1011402,CDM,490,RC,11402,HCPCS,Outpatient,,,1825,1460,,1551.25,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,742.06,130,,,fee schedule,Pays 130% Medicare OPPS,371.75,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,570.17,102,,,fee schedule,Pays 102% Medicare OPPS,1642.5,90,,,percent of total billed charges,90% of total billed charges,638.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1253.78,68.7,,,percent of total billed charges,68.7% of total billed charges,1460,80,,,percent of total billed charges,80 percent of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,503.1,90,,,fee schedule,Pays 90% Medicare OPPS,1058.5,58,,,percent of total billed charges,58% of total billed charges,371.75,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,570.82,100,,,fee schedule,Pays 100% Medicare OPPS,742.06,130,,,fee schedule,Pays 130% Medicare OPPS,1551.25,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,371.75,1642.5,
US DUPLX SCAN PENILE VES,4693980,CDM,921,RC,93980,HCPCS,Outpatient,,,1835,1468,,1559.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,373.79,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1036.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1036.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1036.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1036.78,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,1651.5,90,,,percent of total billed charges,90% of total billed charges,642.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1260.65,68.7,,,percent of total billed charges,68.7% of total billed charges,1468,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,1064.3,58,,,percent of total billed charges,58% of total billed charges,373.79,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,1559.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,1651.5,
NEUPOGEN (FILGRASTIM) INJ 480MCG,2601396,CDM,636,RC,J1441,HCPCS,Both,,,1865,1492,,1585.25,85,,,percent of total billed charges,85% of total billed charges,466.25,100,,,fee schedule,Pays 100% Medicare OPPS,466.25,100,,,fee schedule,Pays 100% Medicare OPPS,466.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,379.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,972.99,52.17,,,case rate,100% of BCBS case rate,972.99,52.17,,,case rate,100% of BCBS case rate,972.99,52.17,,,case rate,100% of BCBS case rate,972.99,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1678.5,90,,,percent of total billed charges,90% of total billed charges,652.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1281.26,68.7,,,percent of total billed charges,68.7% of total billed charges,1492,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1678.5,90,,,fee schedule,Pays 90% Medicare OPPS,1081.7,58,,,percent of total billed charges,58% of total billed charges,379.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1585.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,379.9,1678.5,
NM GASTRIC EMPTYING,4578264,CDM,341,RC,78264,HCPCS,Outpatient,,,1865,1492,,1585.25,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,379.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1053.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1053.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1053.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1053.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,345.39,102,,,fee schedule,Pays 102% Medicare OPPS,1678.5,90,,,percent of total billed charges,90% of total billed charges,652.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1281.26,68.7,,,percent of total billed charges,68.7% of total billed charges,1492,80,,,percent of total billed charges,80 percent of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,304.76,90,,,fee schedule,Pays 90% Medicare OPPS,1081.7,58,,,percent of total billed charges,58% of total billed charges,379.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,341.87,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,1585.25,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,304.76,1678.5,
NM INTESTINE IMAGING,4578290,CDM,341,RC,78290,HCPCS,Outpatient,,,1865,1492,,1585.25,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,379.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1053.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1053.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1053.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1053.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,345.39,102,,,fee schedule,Pays 102% Medicare OPPS,1678.5,90,,,percent of total billed charges,90% of total billed charges,652.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1281.26,68.7,,,percent of total billed charges,68.7% of total billed charges,1492,80,,,percent of total billed charges,80 percent of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,304.76,90,,,fee schedule,Pays 90% Medicare OPPS,1081.7,58,,,percent of total billed charges,58% of total billed charges,379.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,341.87,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,1585.25,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,304.76,1678.5,
PLACEMENT OF BREAST LOCALIZATION DEVICE,4619285,CDM,761,RC,19285,HCPCS,Outpatient,,,1875,1500,,1593.75,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,742.06,130,,,fee schedule,Pays 130% Medicare OPPS,381.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1059.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1059.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1059.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1059.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,570.18,102,,,fee schedule,Pays 102% Medicare OPPS,1687.5,90,,,percent of total billed charges,90% of total billed charges,656.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1288.13,68.7,,,percent of total billed charges,68.7% of total billed charges,1500,80,,,percent of total billed charges,80 percent of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,503.1,90,,,fee schedule,Pays 90% Medicare OPPS,1087.5,58,,,percent of total billed charges,58% of total billed charges,381.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,570.82,100,,,fee schedule,Pays 100% Medicare OPPS,742.06,130,,,fee schedule,Pays 130% Medicare OPPS,1593.75,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,381.94,1687.5,
FERAHEME (FERUMOXYTOL) INJ 510MG,2600192,CDM,636,RC,Q0138,HCPCS,Both,,,1885,1508,,1602.25,85,,,percent of total billed charges,85% of total billed charges,0.53,100,,,fee schedule,Pays 100% Medicare OPPS,0.53,100,,,fee schedule,Pays 100% Medicare OPPS,0.53,100,,,fee schedule,Pays 100% Medicare OPPS,0.65,130,,,fee schedule,Pays 130% Medicare OPPS,0.64,120.37,,,fee schedule,120.37% of custom fee schedule,983.42,52.17,,,case rate,100% of BCBS case rate,983.42,52.17,,,case rate,100% of BCBS case rate,983.42,52.17,,,case rate,100% of BCBS case rate,983.42,52.17,,,case rate,100% of BCBS case rate,0.54,102,,,fee schedule,Pays 102% Medicare OPPS,1696.5,90,,,percent of total billed charges,90% of total billed charges,0.66,125.18,,,fee schedule,125.18% of custom fee schedule,1295,68.7,,,percent of total billed charges,68.7% of total billed charges,1508,80,,,percent of total billed charges,80 percent of total billed charges,0.53,100,,,fee schedule,Pays 100% Medicare OPPS,0.47,90,,,fee schedule,Pays 90% Medicare OPPS,1093.3,58,,,percent of total billed charges,58% of total billed charges,0.64,120.37,,,fee schedule,120.37% of custom fee schedule,0.5,100,,,fee schedule,Pays 100% Medicare OPPS,0.65,130,,,fee schedule,Pays 130% Medicare OPPS,1602.25,85,,,percent of total billed charges,85% of total billed charges,0.53,100,,,fee schedule,Pays 100% Medicare OPPS,0.47,1696.5,
"A procedure most commonly ordered to detect areas of abnormal bone growth due to fractures, tumors, infection, or other bone issues",4578306,CDM,341,RC,78306,HCPCS,Outpatient,,,1890,1512,,1606.5,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,384.99,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1067.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1067.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1067.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1067.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,345.39,102,,,fee schedule,Pays 102% Medicare OPPS,1701,90,,,percent of total billed charges,90% of total billed charges,661.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1298.43,68.7,,,percent of total billed charges,68.7% of total billed charges,1512,80,,,percent of total billed charges,80 percent of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,304.76,90,,,fee schedule,Pays 90% Medicare OPPS,1096.2,58,,,percent of total billed charges,58% of total billed charges,384.99,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,341.87,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,1606.5,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,304.76,1701,
BALLOON DISSECTION OVAL OMSXB2,7950120,CDM,270,RC,,,Outpatient,,,1890,1512,,1606.5,85,,,percent of total billed charges,85% of total billed charges,472.5,100,,,fee schedule,Pays 100% Medicare OPPS,472.5,100,,,fee schedule,Pays 100% Medicare OPPS,472.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,384.99,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1067.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1067.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1067.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1067.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1701,90,,,percent of total billed charges,90% of total billed charges,661.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1298.43,68.7,,,percent of total billed charges,68.7% of total billed charges,1512,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1701,90,,,fee schedule,Pays 90% Medicare OPPS,1096.2,58,,,percent of total billed charges,58% of total billed charges,384.99,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1606.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,384.99,1701,
CHOLECYSTECTOMY TRAY LCB52S,7950148,CDM,272,RC,,,Outpatient,,,1900,1520,,1615,85,,,percent of total billed charges,85% of total billed charges,475,100,,,fee schedule,Pays 100% Medicare OPPS,475,100,,,fee schedule,Pays 100% Medicare OPPS,475,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,387.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1073.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1073.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1073.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1073.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1710,90,,,percent of total billed charges,90% of total billed charges,665,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1305.3,68.7,,,percent of total billed charges,68.7% of total billed charges,1520,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1710,90,,,fee schedule,Pays 90% Medicare OPPS,1102,58,,,percent of total billed charges,58% of total billed charges,387.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1615,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,387.03,1710,
CHOLECYSTECTOMY TRAY FNC43XL,7950151,CDM,272,RC,,,Outpatient,,,1900,1520,,1615,85,,,percent of total billed charges,85% of total billed charges,475,100,,,fee schedule,Pays 100% Medicare OPPS,475,100,,,fee schedule,Pays 100% Medicare OPPS,475,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,387.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1073.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1073.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1073.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1073.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1710,90,,,percent of total billed charges,90% of total billed charges,665,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1305.3,68.7,,,percent of total billed charges,68.7% of total billed charges,1520,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1710,90,,,fee schedule,Pays 90% Medicare OPPS,1102,58,,,percent of total billed charges,58% of total billed charges,387.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1615,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,387.03,1710,
NM RENAL SCAN W/CAPTOPRIL,4578709,CDM,341,RC,78709,HCPCS,Outpatient,,,1910,1528,,1623.5,85,,,percent of total billed charges,85% of total billed charges,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,576.87,130,,,fee schedule,Pays 130% Medicare OPPS,389.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1079.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1079.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1079.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1079.15,56.5,,,percent of total billed charges,56.5 percent of total billed charges,448.38,102,,,fee schedule,Pays 102% Medicare OPPS,1719,90,,,percent of total billed charges,90% of total billed charges,668.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1312.17,68.7,,,percent of total billed charges,68.7% of total billed charges,1528,80,,,percent of total billed charges,80 percent of total billed charges,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,395.63,90,,,fee schedule,Pays 90% Medicare OPPS,1107.8,58,,,percent of total billed charges,58% of total billed charges,389.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,443.74,100,,,fee schedule,Pays 100% Medicare OPPS,576.87,130,,,fee schedule,Pays 130% Medicare OPPS,1623.5,85,,,percent of total billed charges,85% of total billed charges,439.59,100,,,fee schedule,Pays 100% Medicare OPPS,389.07,1719,
PROBE EHL BILIARY SPYGLASS DS,1750053,CDM,272,RC,,,Outpatient,,,1920,1536,,1632,85,,,percent of total billed charges,85% of total billed charges,480,100,,,fee schedule,Pays 100% Medicare OPPS,480,100,,,fee schedule,Pays 100% Medicare OPPS,480,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,391.1,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1084.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1084.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1084.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1084.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1728,90,,,percent of total billed charges,90% of total billed charges,672,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1319.04,68.7,,,percent of total billed charges,68.7% of total billed charges,1536,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1728,90,,,fee schedule,Pays 90% Medicare OPPS,1113.6,58,,,percent of total billed charges,58% of total billed charges,391.1,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1632,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,391.1,1728,
N BLOCK INJ INTERCOST SNG,2064420,CDM,450,RC,64420,HCPCS,Outpatient,,,1925,1540,,1636.25,85,,,percent of total billed charges,85% of total billed charges,570.41,100,,,fee schedule,Pays 100% Medicare OPPS,570.41,100,,,fee schedule,Pays 100% Medicare OPPS,570.41,100,,,fee schedule,Pays 100% Medicare OPPS,736.77,130,,,fee schedule,Pays 130% Medicare OPPS,392.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1087.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1087.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1087.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1087.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,581.83,102,,,fee schedule,Pays 102% Medicare OPPS,1732.5,90,,,percent of total billed charges,90% of total billed charges,673.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1322.48,68.7,,,percent of total billed charges,68.7% of total billed charges,1540,80,,,percent of total billed charges,80 percent of total billed charges,570.41,100,,,fee schedule,Pays 100% Medicare OPPS,513.37,90,,,fee schedule,Pays 90% Medicare OPPS,1116.5,58,,,percent of total billed charges,58% of total billed charges,392.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,566.74,100,,,fee schedule,Pays 100% Medicare OPPS,736.77,130,,,fee schedule,Pays 130% Medicare OPPS,1636.25,85,,,percent of total billed charges,85% of total billed charges,570.41,100,,,fee schedule,Pays 100% Medicare OPPS,392.12,1732.5,
NM THREE PHASE BONE SCAN,4578315,CDM,341,RC,78315,HCPCS,Outpatient,,,1925,1540,,1636.25,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,392.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1087.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1087.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1087.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1087.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,345.39,102,,,fee schedule,Pays 102% Medicare OPPS,1732.5,90,,,percent of total billed charges,90% of total billed charges,673.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1322.48,68.7,,,percent of total billed charges,68.7% of total billed charges,1540,80,,,percent of total billed charges,80 percent of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,304.76,90,,,fee schedule,Pays 90% Medicare OPPS,1116.5,58,,,percent of total billed charges,58% of total billed charges,392.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,341.87,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,1636.25,85,,,percent of total billed charges,85% of total billed charges,338.63,100,,,fee schedule,Pays 100% Medicare OPPS,304.76,1732.5,
FIXATION DEVICE PROTACK 5MM,7950125,CDM,272,RC,,,Outpatient,,,1925,1540,,1636.25,85,,,percent of total billed charges,85% of total billed charges,481.25,100,,,fee schedule,Pays 100% Medicare OPPS,481.25,100,,,fee schedule,Pays 100% Medicare OPPS,481.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,392.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1087.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1087.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1087.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1087.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1732.5,90,,,percent of total billed charges,90% of total billed charges,673.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1322.48,68.7,,,percent of total billed charges,68.7% of total billed charges,1540,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1732.5,90,,,fee schedule,Pays 90% Medicare OPPS,1116.5,58,,,percent of total billed charges,58% of total billed charges,392.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1636.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,392.12,1732.5,
HERNIA PERFIX PLUG 0112780,1570004,CDM,278,RC,C1781,HCPCS,Both,,,1950,1560,,1657.5,85,,,percent of total billed charges,85% of total billed charges,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,397.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1755,90,,,percent of total billed charges,90% of total billed charges,682.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1339.65,68.7,,,percent of total billed charges,68.7% of total billed charges,1560,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1755,90,,,fee schedule,Pays 90% Medicare OPPS,1131,58,,,percent of total billed charges,58% of total billed charges,397.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1657.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,397.22,1755,
HERNIA PATCH KUGEL 3 X 3,1570006,CDM,278,RC,C1781,HCPCS,Both,,,1950,1560,,1657.5,85,,,percent of total billed charges,85% of total billed charges,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,397.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1755,90,,,percent of total billed charges,90% of total billed charges,682.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1339.65,68.7,,,percent of total billed charges,68.7% of total billed charges,1560,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1755,90,,,fee schedule,Pays 90% Medicare OPPS,1131,58,,,percent of total billed charges,58% of total billed charges,397.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1657.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,397.22,1755,
HERNIA PATCH KUGEL 3 X 4.6,1570007,CDM,278,RC,C1781,HCPCS,Both,,,1950,1560,,1657.5,85,,,percent of total billed charges,85% of total billed charges,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,397.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1755,90,,,percent of total billed charges,90% of total billed charges,682.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1339.65,68.7,,,percent of total billed charges,68.7% of total billed charges,1560,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1755,90,,,fee schedule,Pays 90% Medicare OPPS,1131,58,,,percent of total billed charges,58% of total billed charges,397.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1657.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,397.22,1755,
HERNIA PATCH KUGEL 4.34 X 5.5,1570008,CDM,278,RC,C1781,HCPCS,Both,,,1950,1560,,1657.5,85,,,percent of total billed charges,85% of total billed charges,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,397.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1755,90,,,percent of total billed charges,90% of total billed charges,682.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1339.65,68.7,,,percent of total billed charges,68.7% of total billed charges,1560,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1755,90,,,fee schedule,Pays 90% Medicare OPPS,1131,58,,,percent of total billed charges,58% of total billed charges,397.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1657.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,397.22,1755,
HERNIA SURGIMESH WN T1115-8,1570049,CDM,278,RC,C1781,HCPCS,Both,,,1950,1560,,1657.5,85,,,percent of total billed charges,85% of total billed charges,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,397.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1755,90,,,percent of total billed charges,90% of total billed charges,682.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1339.65,68.7,,,percent of total billed charges,68.7% of total billed charges,1560,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1755,90,,,fee schedule,Pays 90% Medicare OPPS,1131,58,,,percent of total billed charges,58% of total billed charges,397.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1657.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,397.22,1755,
HERNIA PATCH KUGEL 4.34 X 5.5,7902000,CDM,278,RC,C1781,HCPCS,Both,,,1950,1560,,1657.5,85,,,percent of total billed charges,85% of total billed charges,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,397.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1755,90,,,percent of total billed charges,90% of total billed charges,682.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1339.65,68.7,,,percent of total billed charges,68.7% of total billed charges,1560,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1755,90,,,fee schedule,Pays 90% Medicare OPPS,1131,58,,,percent of total billed charges,58% of total billed charges,397.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1657.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,397.22,1755,
HERNIA PATCH KUGEL 5.5 X 7,7902001,CDM,278,RC,C1781,HCPCS,Both,,,1950,1560,,1657.5,85,,,percent of total billed charges,85% of total billed charges,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,397.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1755,90,,,percent of total billed charges,90% of total billed charges,682.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1339.65,68.7,,,percent of total billed charges,68.7% of total billed charges,1560,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1755,90,,,fee schedule,Pays 90% Medicare OPPS,1131,58,,,percent of total billed charges,58% of total billed charges,397.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1657.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,397.22,1755,
HERNIA PATCH KUGEL 3 X 4.6,7905157,CDM,278,RC,C1781,HCPCS,Both,,,1950,1560,,1657.5,85,,,percent of total billed charges,85% of total billed charges,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,397.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1755,90,,,percent of total billed charges,90% of total billed charges,682.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1339.65,68.7,,,percent of total billed charges,68.7% of total billed charges,1560,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1755,90,,,fee schedule,Pays 90% Medicare OPPS,1131,58,,,percent of total billed charges,58% of total billed charges,397.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1657.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,397.22,1755,
HERNIA PATCH KUGEL 3 X 3,7905226,CDM,278,RC,C1781,HCPCS,Both,,,1950,1560,,1657.5,85,,,percent of total billed charges,85% of total billed charges,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,397.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1755,90,,,percent of total billed charges,90% of total billed charges,682.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1339.65,68.7,,,percent of total billed charges,68.7% of total billed charges,1560,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1755,90,,,fee schedule,Pays 90% Medicare OPPS,1131,58,,,percent of total billed charges,58% of total billed charges,397.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1657.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,397.22,1755,
HERNIA PERFIX PLUG 0112760,7950240,CDM,278,RC,C1781,HCPCS,Both,,,1950,1560,,1657.5,85,,,percent of total billed charges,85% of total billed charges,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,397.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1755,90,,,percent of total billed charges,90% of total billed charges,682.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1339.65,68.7,,,percent of total billed charges,68.7% of total billed charges,1560,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1755,90,,,fee schedule,Pays 90% Medicare OPPS,1131,58,,,percent of total billed charges,58% of total billed charges,397.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1657.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,397.22,1755,
HERNIA PERFIX PLUG 0112770,7950241,CDM,278,RC,C1781,HCPCS,Both,,,1950,1560,,1657.5,85,,,percent of total billed charges,85% of total billed charges,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,487.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,397.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,1017.33,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1755,90,,,percent of total billed charges,90% of total billed charges,682.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1339.65,68.7,,,percent of total billed charges,68.7% of total billed charges,1560,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1755,90,,,fee schedule,Pays 90% Medicare OPPS,1131,58,,,percent of total billed charges,58% of total billed charges,397.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1657.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,397.22,1755,
DRILL BIT 2.0 CANNULATED,1570355,CDM,278,RC,A4649,HCPCS,Both,,,1970,1576,,1674.5,85,,,percent of total billed charges,85% of total billed charges,492.5,100,,,fee schedule,Pays 100% Medicare OPPS,492.5,100,,,fee schedule,Pays 100% Medicare OPPS,492.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,401.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1027.77,52.17,,,case rate,100% of BCBS case rate,1027.77,52.17,,,case rate,100% of BCBS case rate,1027.77,52.17,,,case rate,100% of BCBS case rate,1027.77,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1773,90,,,percent of total billed charges,90% of total billed charges,689.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1353.39,68.7,,,percent of total billed charges,68.7% of total billed charges,1576,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,1773,90,,,fee schedule,Pays 90% Medicare OPPS,1142.6,58,,,percent of total billed charges,58% of total billed charges,401.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1674.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,401.29,1773,
ESOPHAGUS MOTILITY STUDY (MONOMETRY),1791010,CDM,750,RC,91010,HCPCS,Outpatient,,,1970,1576,,1674.5,85,,,percent of total billed charges,85% of total billed charges,438.49,100,,,fee schedule,Pays 100% Medicare OPPS,438.49,100,,,fee schedule,Pays 100% Medicare OPPS,438.49,100,,,fee schedule,Pays 100% Medicare OPPS,552.77,130,,,fee schedule,Pays 130% Medicare OPPS,401.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,447.26,102,,,fee schedule,Pays 102% Medicare OPPS,1773,90,,,percent of total billed charges,90% of total billed charges,689.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1353.39,68.7,,,percent of total billed charges,68.7% of total billed charges,1576,80,,,percent of total billed charges,80 percent of total billed charges,438.49,100,,,fee schedule,Pays 100% Medicare OPPS,394.64,90,,,fee schedule,Pays 90% Medicare OPPS,1142.6,58,,,percent of total billed charges,58% of total billed charges,401.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,425.21,100,,,fee schedule,Pays 100% Medicare OPPS,552.77,130,,,fee schedule,Pays 130% Medicare OPPS,1674.5,85,,,percent of total billed charges,85% of total billed charges,438.49,100,,,fee schedule,Pays 100% Medicare OPPS,394.64,1773,
G ESOPH REFLUX MUCOSAL PH,1791035,CDM,750,RC,91035,HCPCS,Outpatient,,,1970,1576,,1674.5,85,,,percent of total billed charges,85% of total billed charges,438.49,100,,,fee schedule,Pays 100% Medicare OPPS,438.49,100,,,fee schedule,Pays 100% Medicare OPPS,438.49,100,,,fee schedule,Pays 100% Medicare OPPS,552.77,130,,,fee schedule,Pays 130% Medicare OPPS,401.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,447.26,102,,,fee schedule,Pays 102% Medicare OPPS,1773,90,,,percent of total billed charges,90% of total billed charges,689.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1353.39,68.7,,,percent of total billed charges,68.7% of total billed charges,1576,80,,,percent of total billed charges,80 percent of total billed charges,438.49,100,,,fee schedule,Pays 100% Medicare OPPS,394.64,90,,,fee schedule,Pays 90% Medicare OPPS,1142.6,58,,,percent of total billed charges,58% of total billed charges,401.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,425.21,100,,,fee schedule,Pays 100% Medicare OPPS,552.77,130,,,fee schedule,Pays 130% Medicare OPPS,1674.5,85,,,percent of total billed charges,85% of total billed charges,438.49,100,,,fee schedule,Pays 100% Medicare OPPS,394.64,1773,
CENTRAL LINE PLACEMENT,2036556,CDM,450,RC,36556,HCPCS,Outpatient,,,1970,1576,,1674.5,85,,,percent of total billed charges,85% of total billed charges,2571.56,100,,,fee schedule,Pays 100% Medicare OPPS,2571.56,100,,,fee schedule,Pays 100% Medicare OPPS,2571.56,100,,,fee schedule,Pays 100% Medicare OPPS,3406.31,130,,,fee schedule,Pays 130% Medicare OPPS,401.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1113.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1113.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1113.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1113.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2622.99,102,,,fee schedule,Pays 102% Medicare OPPS,1773,90,,,percent of total billed charges,90% of total billed charges,689.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1353.39,68.7,,,percent of total billed charges,68.7% of total billed charges,1576,80,,,percent of total billed charges,80 percent of total billed charges,2571.56,100,,,fee schedule,Pays 100% Medicare OPPS,2314.4,90,,,fee schedule,Pays 90% Medicare OPPS,1142.6,58,,,percent of total billed charges,58% of total billed charges,401.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2620.23,100,,,fee schedule,Pays 100% Medicare OPPS,3406.31,130,,,fee schedule,Pays 130% Medicare OPPS,1674.5,85,,,percent of total billed charges,85% of total billed charges,2571.56,100,,,fee schedule,Pays 100% Medicare OPPS,401.29,3406.31,
Stress test with echocardiogram,5793350,CDM,483,RC,93350,HCPCS,Outpatient,,,1970,1576,,1674.5,85,,,percent of total billed charges,85% of total billed charges,434.05,100,,,fee schedule,Pays 100% Medicare OPPS,434.05,100,,,fee schedule,Pays 100% Medicare OPPS,434.05,100,,,fee schedule,Pays 100% Medicare OPPS,575.29,130,,,fee schedule,Pays 130% Medicare OPPS,401.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,442.72,102,,,fee schedule,Pays 102% Medicare OPPS,1773,90,,,percent of total billed charges,90% of total billed charges,689.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1353.39,68.7,,,percent of total billed charges,68.7% of total billed charges,1576,80,,,percent of total billed charges,80 percent of total billed charges,434.05,100,,,fee schedule,Pays 100% Medicare OPPS,390.64,90,,,fee schedule,Pays 90% Medicare OPPS,1142.6,58,,,percent of total billed charges,58% of total billed charges,401.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,442.54,100,,,fee schedule,Pays 100% Medicare OPPS,575.29,130,,,fee schedule,Pays 130% Medicare OPPS,1674.5,85,,,percent of total billed charges,85% of total billed charges,434.05,100,,,fee schedule,Pays 100% Medicare OPPS,390.64,1773,
EXCISION BENIGN LESION <.5 cm,1011400,CDM,490,RC,11400,HCPCS,Outpatient,,,1990,1592,,1691.5,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,742.06,130,,,fee schedule,Pays 130% Medicare OPPS,405.36,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,570.17,102,,,fee schedule,Pays 102% Medicare OPPS,1791,90,,,percent of total billed charges,90% of total billed charges,696.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1367.13,68.7,,,percent of total billed charges,68.7% of total billed charges,1592,80,,,percent of total billed charges,80 percent of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,503.1,90,,,fee schedule,Pays 90% Medicare OPPS,1154.2,58,,,percent of total billed charges,58% of total billed charges,405.36,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,570.82,100,,,fee schedule,Pays 100% Medicare OPPS,742.06,130,,,fee schedule,Pays 130% Medicare OPPS,1691.5,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,405.36,1791,
Under Excision-Benign Lesions Procedures on the Skin 0.6-1 CM,1011401,CDM,490,RC,11401,HCPCS,Outpatient,,,1990,1592,,1691.5,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,405.36,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,316.7,102,,,fee schedule,Pays 102% Medicare OPPS,1791,90,,,percent of total billed charges,90% of total billed charges,696.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1367.13,68.7,,,percent of total billed charges,68.7% of total billed charges,1592,80,,,percent of total billed charges,80 percent of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,279.44,90,,,fee schedule,Pays 90% Medicare OPPS,1154.2,58,,,percent of total billed charges,58% of total billed charges,405.36,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,328.14,100,,,fee schedule,Pays 100% Medicare OPPS,426.58,130,,,fee schedule,Pays 130% Medicare OPPS,1691.5,85,,,percent of total billed charges,85% of total billed charges,310.49,100,,,fee schedule,Pays 100% Medicare OPPS,279.44,1791,
REPAIR COMPLEX E/N/E/L 1.1-2.5 CM,2013151,CDM,450,RC,13151,HCPCS,Outpatient,,,1990,1592,,1691.5,85,,,percent of total billed charges,85% of total billed charges,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,664.28,130,,,fee schedule,Pays 130% Medicare OPPS,405.36,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1124.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1124.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1124.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1124.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,479.88,102,,,fee schedule,Pays 102% Medicare OPPS,1791,90,,,percent of total billed charges,90% of total billed charges,696.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1367.13,68.7,,,percent of total billed charges,68.7% of total billed charges,1592,80,,,percent of total billed charges,80 percent of total billed charges,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,423.42,90,,,fee schedule,Pays 90% Medicare OPPS,1154.2,58,,,percent of total billed charges,58% of total billed charges,405.36,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,510.99,100,,,fee schedule,Pays 100% Medicare OPPS,664.28,130,,,fee schedule,Pays 130% Medicare OPPS,1691.5,85,,,percent of total billed charges,85% of total billed charges,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,405.36,1791,
REPAIR COMPLEX 2.6CM-7.5CM,2013152,CDM,450,RC,13152,HCPCS,Outpatient,,,1990,1592,,1691.5,85,,,percent of total billed charges,85% of total billed charges,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,664.28,130,,,fee schedule,Pays 130% Medicare OPPS,405.36,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1124.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1124.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1124.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1124.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,479.88,102,,,fee schedule,Pays 102% Medicare OPPS,1791,90,,,percent of total billed charges,90% of total billed charges,696.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1367.13,68.7,,,percent of total billed charges,68.7% of total billed charges,1592,80,,,percent of total billed charges,80 percent of total billed charges,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,423.42,90,,,fee schedule,Pays 90% Medicare OPPS,1154.2,58,,,percent of total billed charges,58% of total billed charges,405.36,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,510.99,100,,,fee schedule,Pays 100% Medicare OPPS,664.28,130,,,fee schedule,Pays 130% Medicare OPPS,1691.5,85,,,percent of total billed charges,85% of total billed charges,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,405.36,1791,
3RD TPMT GENOTYPE,3000635,CDM,300,RC,81401,HCPCS,Outpatient,,,1990,1592,,1691.5,85,,,percent of total billed charges,85% of total billed charges,137,100,,,fee schedule,Pays 100% Medicare OPPS,137,100,,,fee schedule,Pays 100% Medicare OPPS,137,100,,,fee schedule,Pays 100% Medicare OPPS,178.1,130,APC,,fee schedule,Pays 130% Medicare OPPS,134.81,120.37,,,fee schedule,120.37% of custom fee schedule,1124.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1124.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1124.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1124.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,139.74,102,,,fee schedule,Pays 102% Medicare OPPS,1791,90,,,percent of total billed charges,90% of total billed charges,140.2,125.18,,,fee schedule,125.18% of custom fee schedule,1367.13,68.7,,,percent of total billed charges,68.7% of total billed charges,1592,80,,,percent of total billed charges,80 percent of total billed charges,137,100,,,fee schedule,Pays 100% Medicare OPPS,123.3,90,,,fee schedule,Pays 90% Medicare OPPS,1154.2,58,,,percent of total billed charges,58% of total billed charges,134.81,120.37,,,fee schedule,120.37% of custom fee schedule,137,100,,,fee schedule,Pays 100% Medicare OPPS,178.1,130,APC,,fee schedule,Pays 130% Medicare OPPS,1691.5,85,,,percent of total billed charges,85% of total billed charges,137,100,,,fee schedule,Pays 100% Medicare OPPS,123.3,1791,
INTEGRILIN (EPTIFIBAT.) 0.75MG/1ML 100ML,2605030,CDM,636,RC,J1327,HCPCS,Both,,,1995,1596,,1695.75,85,,,percent of total billed charges,85% of total billed charges,1.87,100,,,fee schedule,Pays 100% Medicare OPPS,1.87,100,,,fee schedule,Pays 100% Medicare OPPS,1.87,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,406.38,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1040.81,52.17,,,case rate,100% of BCBS case rate,1040.81,52.17,,,case rate,100% of BCBS case rate,1040.81,52.17,,,case rate,100% of BCBS case rate,1040.81,52.17,,,case rate,100% of BCBS case rate,1.9,102,,,fee schedule,Pays 102% Medicare OPPS,1795.5,90,,,percent of total billed charges,90% of total billed charges,698.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1370.57,68.7,,,percent of total billed charges,68.7% of total billed charges,1596,80,,,percent of total billed charges,80 percent of total billed charges,1.87,100,,,fee schedule,Pays 100% Medicare OPPS,1.68,90,,,fee schedule,Pays 90% Medicare OPPS,1157.1,58,,,percent of total billed charges,58% of total billed charges,406.38,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1695.75,85,,,percent of total billed charges,85% of total billed charges,1.87,100,,,fee schedule,Pays 100% Medicare OPPS,1.68,1795.5,
DEBRIDEMENT MUSCLE/FASCIA 20 SQ CM/<,1511043,CDM,360,RC,11043,HCPCS,Outpatient,,,2000,1600,,1700,85,,,percent of total billed charges,85% of total billed charges,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,664.28,130,,,fee schedule,Pays 130% Medicare OPPS,407.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,479.88,102,,,fee schedule,Pays 102% Medicare OPPS,1800,90,,,percent of total billed charges,90% of total billed charges,700,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1374,68.7,,,percent of total billed charges,68.7% of total billed charges,1600,80,,,percent of total billed charges,80 percent of total billed charges,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,423.42,90,,,fee schedule,Pays 90% Medicare OPPS,1160,58,,,percent of total billed charges,58% of total billed charges,407.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,510.99,100,,,fee schedule,Pays 100% Medicare OPPS,664.28,130,,,fee schedule,Pays 130% Medicare OPPS,1700,85,,,percent of total billed charges,85% of total billed charges,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,407.4,1800,
HERNIA PATCH PROCEED VENTRAL PVPM,1570054,CDM,278,RC,C1781,HCPCS,Both,,,2010,1608,,1708.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,409.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1048.64,52.17,,,case rate,100% of BCBS case rate,1048.64,52.17,,,case rate,100% of BCBS case rate,1048.64,52.17,,,case rate,100% of BCBS case rate,1048.64,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1809,90,,,percent of total billed charges,90% of total billed charges,703.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1380.87,68.7,,,percent of total billed charges,68.7% of total billed charges,1608,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1165.8,58,,,percent of total billed charges,58% of total billed charges,409.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1708.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,409.44,1809,
SINUS ILLUMINATION SYSTEM SIS100B,1570750,CDM,272,RC,,,Outpatient,,,2015,1612,,1712.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,410.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1138.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1138.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1138.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1138.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1813.5,90,,,percent of total billed charges,90% of total billed charges,705.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1384.31,68.7,,,percent of total billed charges,68.7% of total billed charges,1612,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1168.7,58,,,percent of total billed charges,58% of total billed charges,410.46,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1712.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,410.46,1813.5,
LENS INTRAOCULAR RESTOR SN6AD1 23.0,1570248,CDM,276,RC,V2797,HCPCS,Outpatient,,,2035,1628,,1729.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,414.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1061.68,52.17,,,case rate,100% of BCBS case rate,1061.68,52.17,,,case rate,100% of BCBS case rate,1061.68,52.17,,,case rate,100% of BCBS case rate,1061.68,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1831.5,90,,,percent of total billed charges,90% of total billed charges,712.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1398.05,68.7,,,percent of total billed charges,68.7% of total billed charges,1628,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1180.3,58,,,percent of total billed charges,58% of total billed charges,414.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1729.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,414.53,1831.5,
LENS INTRAOCULAR RESTOR SN6AD1 23.5,1570251,CDM,276,RC,V2797,HCPCS,Outpatient,,,2035,1628,,1729.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,414.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1061.68,52.17,,,case rate,100% of BCBS case rate,1061.68,52.17,,,case rate,100% of BCBS case rate,1061.68,52.17,,,case rate,100% of BCBS case rate,1061.68,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1831.5,90,,,percent of total billed charges,90% of total billed charges,712.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1398.05,68.7,,,percent of total billed charges,68.7% of total billed charges,1628,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1180.3,58,,,percent of total billed charges,58% of total billed charges,414.53,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1729.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,414.53,1831.5,
"EPOGEN/PROCRIT (EPOETIN) INJ 20,000UNITS",2602236,CDM,636,RC,J0886,HCPCS,Both,,,2065,1652,,1755.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,420.64,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1077.33,52.17,,,case rate,100% of BCBS case rate,1077.33,52.17,,,case rate,100% of BCBS case rate,1077.33,52.17,,,case rate,100% of BCBS case rate,1077.33,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1858.5,90,,,percent of total billed charges,90% of total billed charges,722.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1418.66,68.7,,,percent of total billed charges,68.7% of total billed charges,1652,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1197.7,58,,,percent of total billed charges,58% of total billed charges,420.64,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1755.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,420.64,1858.5,
REPAIR LACERATION TONGUE MOUTH OVER 2.6,2041252,CDM,450,RC,41252,HCPCS,Outpatient,,,2070,1656,,1759.5,85,,,percent of total billed charges,85% of total billed charges,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,237.63,130,,,fee schedule,Pays 130% Medicare OPPS,421.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1169.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1169.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1169.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1169.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,193.85,102,,,fee schedule,Pays 102% Medicare OPPS,1863,90,,,percent of total billed charges,90% of total billed charges,724.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1422.09,68.7,,,percent of total billed charges,68.7% of total billed charges,1656,80,,,percent of total billed charges,80 percent of total billed charges,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,171.04,90,,,fee schedule,Pays 90% Medicare OPPS,1200.6,58,,,percent of total billed charges,58% of total billed charges,421.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,182.8,100,,,fee schedule,Pays 100% Medicare OPPS,237.63,130,,,fee schedule,Pays 130% Medicare OPPS,1759.5,85,,,percent of total billed charges,85% of total billed charges,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,171.04,1863,
LEVEL VI CRITICAL CARE,2099291,CDM,450,RC,99291,HCPCS,Outpatient,,,2110,1688,,1793.5,85,,,percent of total billed charges,85% of total billed charges,669.13,100,,,fee schedule,Pays 100% Medicare OPPS,669.13,100,,,fee schedule,Pays 100% Medicare OPPS,669.13,100,,,fee schedule,Pays 100% Medicare OPPS,877.84,130,,,fee schedule,Pays 130% Medicare OPPS,429.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2110,100,,,percent of total billed charges,671 dollar flat fee for ER,2110,100,,,percent of total billed charges,671 dollar flat fee for ER,2110,100,,,percent of total billed charges,671 dollar flat fee for ER,2110,100,,,percent of total billed charges,671 dollar flat fee for ER,682.51,102,,,fee schedule,Pays 102% Medicare OPPS,1899,90,,,percent of total billed charges,90% of total billed charges,738.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1449.57,68.7,,,percent of total billed charges,68.7% of total billed charges,1688,80,,,percent of total billed charges,80 percent of total billed charges,669.13,100,,,fee schedule,Pays 100% Medicare OPPS,602.21,90,,,fee schedule,Pays 90% Medicare OPPS,1223.8,58,,,percent of total billed charges,58% of total billed charges,429.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,675.27,100,,,fee schedule,Pays 100% Medicare OPPS,877.84,130,,,fee schedule,Pays 130% Medicare OPPS,1793.5,85,,,percent of total billed charges,85% of total billed charges,669.13,100,,,fee schedule,Pays 100% Medicare OPPS,429.81,2110,
XR VENOGRAM RT,4075820,CDM,320,RC,75820,HCPCS,Outpatient,,,2115,1692,,1797.75,85,,,percent of total billed charges,85% of total billed charges,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,1701.28,130,,,fee schedule,Pays 130% Medicare OPPS,430.83,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1194.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1194.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1194.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1188.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1288.48,102,,,fee schedule,Pays 102% Medicare OPPS,1903.5,90,,,percent of total billed charges,90% of total billed charges,740.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1453.01,68.7,,,percent of total billed charges,68.7% of total billed charges,1692,80,,,percent of total billed charges,80 percent of total billed charges,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,1136.89,90,,,fee schedule,Pays 90% Medicare OPPS,1226.7,58,,,percent of total billed charges,58% of total billed charges,430.83,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1308.68,100,,,fee schedule,Pays 100% Medicare OPPS,1701.28,130,,,fee schedule,Pays 130% Medicare OPPS,1797.75,85,,,percent of total billed charges,85% of total billed charges,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,430.83,1903.5,
XR VENOGRAM LT,4085820,CDM,320,RC,75820,HCPCS,Outpatient,,,2115,1692,,1797.75,85,,,percent of total billed charges,85% of total billed charges,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,1701.28,130,,,fee schedule,Pays 130% Medicare OPPS,430.83,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1194.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1194.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1194.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1188.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1288.48,102,,,fee schedule,Pays 102% Medicare OPPS,1903.5,90,,,percent of total billed charges,90% of total billed charges,740.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1453.01,68.7,,,percent of total billed charges,68.7% of total billed charges,1692,80,,,percent of total billed charges,80 percent of total billed charges,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,1136.89,90,,,fee schedule,Pays 90% Medicare OPPS,1226.7,58,,,percent of total billed charges,58% of total billed charges,430.83,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1308.68,100,,,fee schedule,Pays 100% Medicare OPPS,1701.28,130,,,fee schedule,Pays 130% Medicare OPPS,1797.75,85,,,percent of total billed charges,85% of total billed charges,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,430.83,1903.5,
FORCEPS HET BIPOLAR,1750060,CDM,272,RC,,,Outpatient,,,2125,1700,,1806.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,432.86,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1200.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1200.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1200.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1200.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1912.5,90,,,percent of total billed charges,90% of total billed charges,743.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1459.88,68.7,,,percent of total billed charges,68.7% of total billed charges,1700,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1232.5,58,,,percent of total billed charges,58% of total billed charges,432.86,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1806.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,432.86,1912.5,
LENS INTRAOCULAR RESTOR SN6AD3 23.0,1570249,CDM,276,RC,V2797,HCPCS,Outpatient,,,2150,1720,,1827.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,437.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1121.68,52.17,,,case rate,100% of BCBS case rate,1121.68,52.17,,,case rate,100% of BCBS case rate,1121.68,52.17,,,case rate,100% of BCBS case rate,1121.68,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1935,90,,,percent of total billed charges,90% of total billed charges,752.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1477.05,68.7,,,percent of total billed charges,68.7% of total billed charges,1720,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1247,58,,,percent of total billed charges,58% of total billed charges,437.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1827.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,437.96,1935,
LENS INTRAOCULAR RESTOR SN6AD3 23.5,1570250,CDM,276,RC,V2797,HCPCS,Outpatient,,,2150,1720,,1827.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,437.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1121.68,52.17,,,case rate,100% of BCBS case rate,1121.68,52.17,,,case rate,100% of BCBS case rate,1121.68,52.17,,,case rate,100% of BCBS case rate,1121.68,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1935,90,,,percent of total billed charges,90% of total billed charges,752.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1477.05,68.7,,,percent of total billed charges,68.7% of total billed charges,1720,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1247,58,,,percent of total billed charges,58% of total billed charges,437.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1827.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,437.96,1935,
INJ SCLEROSING SOLUTION HEMORRHOIDS,2046500,CDM,360,RC,46500,HCPCS,Outpatient,,,2150,1720,,1827.5,85,,,percent of total billed charges,85% of total billed charges,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,950.25,130,,,fee schedule,Pays 130% Medicare OPPS,437.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,727.13,102,,,fee schedule,Pays 102% Medicare OPPS,1935,90,,,percent of total billed charges,90% of total billed charges,752.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1477.05,68.7,,,percent of total billed charges,68.7% of total billed charges,1720,80,,,percent of total billed charges,80 percent of total billed charges,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,641.59,90,,,fee schedule,Pays 90% Medicare OPPS,1247,58,,,percent of total billed charges,58% of total billed charges,437.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,730.96,100,,,fee schedule,Pays 100% Medicare OPPS,950.25,130,,,fee schedule,Pays 130% Medicare OPPS,1827.5,85,,,percent of total billed charges,85% of total billed charges,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,437.96,1935,
PERQ DEV SOFT TISS 1ST IMG,1510035,CDM,360,RC,10035,HCPCS,Outpatient,,,2175,1740,,1848.75,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,742.06,130,,,fee schedule,Pays 130% Medicare OPPS,443.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,570.17,102,,,fee schedule,Pays 102% Medicare OPPS,1957.5,90,,,percent of total billed charges,90% of total billed charges,761.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1494.23,68.7,,,percent of total billed charges,68.7% of total billed charges,1740,80,,,percent of total billed charges,80 percent of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,503.1,90,,,fee schedule,Pays 90% Medicare OPPS,1261.5,58,,,percent of total billed charges,58% of total billed charges,443.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,570.82,100,,,fee schedule,Pays 100% Medicare OPPS,742.06,130,,,fee schedule,Pays 130% Medicare OPPS,1848.75,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,443.05,1957.5,
BB PLATELET PHERESIS UNIT,3109034,CDM,390,RC,P9034,HCPCS,Outpatient,,,2195,1756,,1865.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,434.16,130,,,fee schedule,Pays 130% Medicare OPPS,447.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1240.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1240.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1240.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1240.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,1975.5,90,,,percent of total billed charges,90% of total billed charges,768.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1507.97,68.7,,,percent of total billed charges,68.7% of total billed charges,1756,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,1273.1,58,,,percent of total billed charges,58% of total billed charges,447.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,333.97,100,,,fee schedule,Pays 100% Medicare OPPS,434.16,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,1975.5,
HERNIA PATCH VENTRALEX ST 6.4CM 5950008,1570057,CDM,278,RC,C1781,HCPCS,Both,,,2215,1772,,1882.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,451.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1155.59,52.17,,,case rate,100% of BCBS case rate,1155.59,52.17,,,case rate,100% of BCBS case rate,1155.59,52.17,,,case rate,100% of BCBS case rate,1155.59,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,1993.5,90,,,percent of total billed charges,90% of total billed charges,775.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1521.71,68.7,,,percent of total billed charges,68.7% of total billed charges,1772,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1284.7,58,,,percent of total billed charges,58% of total billed charges,451.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1882.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,451.2,1993.5,
FORCEPS SPYBITE BIOPSY,1750055,CDM,272,RC,,,Outpatient,,,2215,1772,,1882.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,451.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1251.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1251.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1251.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1251.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,1993.5,90,,,percent of total billed charges,90% of total billed charges,775.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1521.71,68.7,,,percent of total billed charges,68.7% of total billed charges,1772,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1284.7,58,,,percent of total billed charges,58% of total billed charges,451.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1882.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,451.2,1993.5,
REMDESIVIR 100MG VIAL,2610115,CDM,636,RC,,,Both,,,2250,1800,,1912.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,458.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1173.85,52.17,,,case rate,100% of BCBS case rate,1173.85,52.17,,,case rate,100% of BCBS case rate,1173.85,52.17,,,case rate,100% of BCBS case rate,1173.85,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,2025,90,,,percent of total billed charges,90% of total billed charges,787.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1545.75,68.7,,,percent of total billed charges,68.7% of total billed charges,1800,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1305,58,,,percent of total billed charges,58% of total billed charges,458.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1912.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,458.33,2025,
MAGSEED MARKER,2610527,CDM,270,RC,,,Outpatient,,,2250,1800,,1912.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,458.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1271.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1271.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1271.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1271.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,2025,90,,,percent of total billed charges,90% of total billed charges,787.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1545.75,68.7,,,percent of total billed charges,68.7% of total billed charges,1800,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1305,58,,,percent of total billed charges,58% of total billed charges,458.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1912.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,458.33,2025,
XR THYROID BPSY PERCU CORE,4060100,CDM,761,RC,60100,HCPCS,Outpatient,,,2250,1800,,1912.5,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,742.06,130,,,fee schedule,Pays 130% Medicare OPPS,458.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1271.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1271.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1271.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1271.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,570.17,102,,,fee schedule,Pays 102% Medicare OPPS,2025,90,,,percent of total billed charges,90% of total billed charges,787.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1545.75,68.7,,,percent of total billed charges,68.7% of total billed charges,1800,80,,,percent of total billed charges,80 percent of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,503.1,90,,,fee schedule,Pays 90% Medicare OPPS,1305,58,,,percent of total billed charges,58% of total billed charges,458.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,570.82,100,,,fee schedule,Pays 100% Medicare OPPS,742.06,130,,,fee schedule,Pays 130% Medicare OPPS,1912.5,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,458.33,2025,
FIXATION DEVICE SECURESTRAP,7950153,CDM,272,RC,,,Outpatient,,,2290,1832,,1946.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,466.47,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1293.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1293.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1293.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1293.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,2061,90,,,percent of total billed charges,90% of total billed charges,801.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1573.23,68.7,,,percent of total billed charges,68.7% of total billed charges,1832,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1328.2,58,,,percent of total billed charges,58% of total billed charges,466.47,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1946.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,466.47,2061,
CORLOPAM (FENOLDOPAM) INJ : 20MG,2605140,CDM,250,RC,,,Outpatient,,,2345,1876,,1993.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,477.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1324.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1324.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1324.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1324.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,2110.5,90,,,percent of total billed charges,90% of total billed charges,820.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1611.02,68.7,,,percent of total billed charges,68.7% of total billed charges,1876,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1360.1,58,,,percent of total billed charges,58% of total billed charges,477.68,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,1993.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,477.68,2110.5,
I & D PERIANAL ABSCESS,2046050,CDM,450,RC,46050,HCPCS,Outpatient,,,2485,1988,,2112.25,85,,,percent of total billed charges,85% of total billed charges,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,950.25,130,,,fee schedule,Pays 130% Medicare OPPS,506.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1404.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1404.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1404.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1404.03,56.5,,,percent of total billed charges,56.5 percent of total billed charges,727.13,102,,,fee schedule,Pays 102% Medicare OPPS,2236.5,90,,,percent of total billed charges,90% of total billed charges,869.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1707.2,68.7,,,percent of total billed charges,68.7% of total billed charges,1988,80,,,percent of total billed charges,80 percent of total billed charges,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,641.59,90,,,fee schedule,Pays 90% Medicare OPPS,1441.3,58,,,percent of total billed charges,58% of total billed charges,506.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,730.96,100,,,fee schedule,Pays 100% Medicare OPPS,950.25,130,,,fee schedule,Pays 130% Medicare OPPS,2112.25,85,,,percent of total billed charges,85% of total billed charges,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,506.19,2236.5,
A biologic medication,2601412,CDM,636,RC,J1745,HCPCS,Both,,,2490,1992,,2116.5,85,,,percent of total billed charges,85% of total billed charges,35.02,100,,,fee schedule,Pays 100% Medicare OPPS,35.02,100,,,fee schedule,Pays 100% Medicare OPPS,35.02,100,,,fee schedule,Pays 100% Medicare OPPS,42.43,130,,,fee schedule,Pays 130% Medicare OPPS,42.15,120.37,,,fee schedule,120.37% of custom fee schedule,1299.06,52.17,,,case rate,100% of BCBS case rate,1299.06,52.17,,,case rate,100% of BCBS case rate,1299.06,52.17,,,case rate,100% of BCBS case rate,1299.06,52.17,,,case rate,100% of BCBS case rate,35.72,102,,,fee schedule,Pays 102% Medicare OPPS,2241,90,,,percent of total billed charges,90% of total billed charges,43.84,125.18,,,fee schedule,125.18% of custom fee schedule,1710.63,68.7,,,percent of total billed charges,68.7% of total billed charges,1992,80,,,percent of total billed charges,80 percent of total billed charges,35.02,100,,,fee schedule,Pays 100% Medicare OPPS,31.51,90,,,fee schedule,Pays 90% Medicare OPPS,1444.2,58,,,percent of total billed charges,58% of total billed charges,42.15,120.37,,,fee schedule,120.37% of custom fee schedule,32.64,100,,,fee schedule,Pays 100% Medicare OPPS,42.43,130,,,fee schedule,Pays 130% Medicare OPPS,2116.5,85,,,percent of total billed charges,85% of total billed charges,35.02,100,,,fee schedule,Pays 100% Medicare OPPS,31.51,2241,
RA TRACER ID OF SENTINL NODE,1538792,CDM,360,RC,38792,HCPCS,Outpatient,,,2500,2000,,2125,85,,,percent of total billed charges,85% of total billed charges,338.62,100,,,fee schedule,Pays 100% Medicare OPPS,338.62,100,,,fee schedule,Pays 100% Medicare OPPS,338.62,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,509.25,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,345.4,102,,,fee schedule,Pays 102% Medicare OPPS,2250,90,,,percent of total billed charges,90% of total billed charges,875,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1717.5,68.7,,,percent of total billed charges,68.7% of total billed charges,2000,80,,,percent of total billed charges,80 percent of total billed charges,338.62,100,,,fee schedule,Pays 100% Medicare OPPS,304.76,90,,,fee schedule,Pays 90% Medicare OPPS,1450,58,,,percent of total billed charges,58% of total billed charges,509.25,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,341.87,100,,,fee schedule,Pays 100% Medicare OPPS,444.43,130,,,fee schedule,Pays 130% Medicare OPPS,2125,85,,,percent of total billed charges,85% of total billed charges,338.62,100,,,fee schedule,Pays 100% Medicare OPPS,304.76,2250,
"Fine needle aspiration biopsy, including ultrasound guidance; first lesion",4610005,CDM,761,RC,10005,HCPCS,Outpatient,,,2500,2000,,2125,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,742.06,130,,,fee schedule,Pays 130% Medicare OPPS,509.25,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1412.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1412.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1412.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1412.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,570.17,102,,,fee schedule,Pays 102% Medicare OPPS,2250,90,,,percent of total billed charges,90% of total billed charges,875,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1717.5,68.7,,,percent of total billed charges,68.7% of total billed charges,2000,80,,,percent of total billed charges,80 percent of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,503.1,90,,,fee schedule,Pays 90% Medicare OPPS,1450,58,,,percent of total billed charges,58% of total billed charges,509.25,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,570.82,100,,,fee schedule,Pays 100% Medicare OPPS,742.06,130,,,fee schedule,Pays 130% Medicare OPPS,2125,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,503.1,2250,
BIOPSY OF THYROID,4660100,CDM,761,RC,60100,HCPCS,Outpatient,,,2500,2000,,2125,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,742.06,130,,,fee schedule,Pays 130% Medicare OPPS,509.25,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1412.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1412.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1412.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1412.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,570.17,102,,,fee schedule,Pays 102% Medicare OPPS,2250,90,,,percent of total billed charges,90% of total billed charges,875,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1717.5,68.7,,,percent of total billed charges,68.7% of total billed charges,2000,80,,,percent of total billed charges,80 percent of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,503.1,90,,,fee schedule,Pays 90% Medicare OPPS,1450,58,,,percent of total billed charges,58% of total billed charges,509.25,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,570.82,100,,,fee schedule,Pays 100% Medicare OPPS,742.06,130,,,fee schedule,Pays 130% Medicare OPPS,2125,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,503.1,2250,
HERNIA ECHO 2 POSITIONING SYSTEM 5991015,1570382,CDM,278,RC,C1781,HCPCS,Both,,,2565,2052,,2180.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,522.49,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1338.19,52.17,,,case rate,100% of BCBS case rate,1338.19,52.17,,,case rate,100% of BCBS case rate,1338.19,52.17,,,case rate,100% of BCBS case rate,1338.19,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,2308.5,90,,,percent of total billed charges,90% of total billed charges,897.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1762.16,68.7,,,percent of total billed charges,68.7% of total billed charges,2052,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1487.7,58,,,percent of total billed charges,58% of total billed charges,522.49,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2180.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,522.49,2308.5,
"INTUBATION, ENDOTRACHEAL EMERGENCY",1031500,CDM,450,RC,31500,HCPCS,Outpatient,,,2600,2080,,2210,85,,,percent of total billed charges,85% of total billed charges,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,237.63,130,,,fee schedule,Pays 130% Medicare OPPS,529.62,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1469,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1469,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1469,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1469,56.5,,,percent of total billed charges,56.5 percent of total billed charges,193.85,102,,,fee schedule,Pays 102% Medicare OPPS,2340,90,,,percent of total billed charges,90% of total billed charges,910,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1786.2,68.7,,,percent of total billed charges,68.7% of total billed charges,2080,80,,,percent of total billed charges,80 percent of total billed charges,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,171.04,90,,,fee schedule,Pays 90% Medicare OPPS,1508,58,,,percent of total billed charges,58% of total billed charges,529.62,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,182.8,100,,,fee schedule,Pays 100% Medicare OPPS,237.63,130,,,fee schedule,Pays 130% Medicare OPPS,2210,85,,,percent of total billed charges,85% of total billed charges,190.05,100,,,fee schedule,Pays 100% Medicare OPPS,171.04,2340,
Anesthesia for labor during planned vaginal delivery,1801967,CDM,379,RC,1967,HCPCS,Outpatient,,,2600,2080,,2210,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,529.62,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1469,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1469,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1469,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1469,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,2340,90,,,percent of total billed charges,90% of total billed charges,910,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1786.2,68.7,,,percent of total billed charges,68.7% of total billed charges,2080,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1508,58,,,percent of total billed charges,58% of total billed charges,529.62,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,529.62,2340,
ANES NERVE BLOCK DIAG OR THERAPEUTIC,1801991,CDM,379,RC,,,Outpatient,,,2600,2080,,2210,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,529.62,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1469,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1469,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1469,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1469,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,2340,90,,,percent of total billed charges,90% of total billed charges,910,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1786.2,68.7,,,percent of total billed charges,68.7% of total billed charges,2080,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1508,58,,,percent of total billed charges,58% of total billed charges,529.62,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,529.62,2340,
EPIDURAL PAIN MANAGEMENT,1801996,CDM,379,RC,1996,HCPCS,Outpatient,,,2600,2080,,2210,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,529.62,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1469,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1469,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1469,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1469,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,2340,90,,,percent of total billed charges,90% of total billed charges,910,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1786.2,68.7,,,percent of total billed charges,68.7% of total billed charges,2080,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1508,58,,,percent of total billed charges,58% of total billed charges,529.62,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,529.62,2340,
EMERGENCY INTUBATION ANES,1801999,CDM,379,RC,1999,HCPCS,Outpatient,,,2600,2080,,2210,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,529.62,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1469,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1469,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1469,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1469,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,2340,90,,,percent of total billed charges,90% of total billed charges,910,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1786.2,68.7,,,percent of total billed charges,68.7% of total billed charges,2080,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1508,58,,,percent of total billed charges,58% of total billed charges,529.62,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursed per contract,,,,,other,Not reimbursable per contract,529.62,2340,
BOTOX 100 UNIT VIAL,2620008,CDM,636,RC,J0585,HCPCS,Both,,,2625,2100,,2231.25,85,,,percent of total billed charges,85% of total billed charges,6.23,100,,,fee schedule,Pays 100% Medicare OPPS,6.23,100,,,fee schedule,Pays 100% Medicare OPPS,6.23,100,,,fee schedule,Pays 100% Medicare OPPS,8.22,130,,,fee schedule,Pays 130% Medicare OPPS,7.5,120.37,,,fee schedule,120.37% of custom fee schedule,1369.49,52.17,,,case rate,100% of BCBS case rate,1369.49,52.17,,,case rate,100% of BCBS case rate,1369.49,52.17,,,case rate,100% of BCBS case rate,1369.49,52.17,,,case rate,100% of BCBS case rate,6.35,102,,,fee schedule,Pays 102% Medicare OPPS,2362.5,90,,,percent of total billed charges,90% of total billed charges,7.8,125.18,,,fee schedule,125.18% of custom fee schedule,1803.38,68.7,,,percent of total billed charges,68.7% of total billed charges,2100,80,,,percent of total billed charges,80 percent of total billed charges,6.23,100,,,fee schedule,Pays 100% Medicare OPPS,5.6,90,,,fee schedule,Pays 90% Medicare OPPS,1522.5,58,,,percent of total billed charges,58% of total billed charges,7.5,120.37,,,fee schedule,120.37% of custom fee schedule,6.33,100,,,fee schedule,Pays 100% Medicare OPPS,8.22,130,,,fee schedule,Pays 130% Medicare OPPS,2231.25,85,,,percent of total billed charges,85% of total billed charges,6.23,100,,,fee schedule,Pays 100% Medicare OPPS,5.6,2362.5,
ANCHORS 8 TENDON,1570870,CDM,278,RC,29827,HCPCS,Both,,,2700,2160,,2295,85,,,percent of total billed charges,85% of total billed charges,5626.71,100,,,fee schedule,Pays 100% Medicare OPPS,5626.71,100,,,fee schedule,Pays 100% Medicare OPPS,5626.71,100,,,fee schedule,Pays 100% Medicare OPPS,7563.51,130,,,fee schedule,Pays 130% Medicare OPPS,549.99,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1408.62,52.17,,,case rate,100% of BCBS case rate,1408.62,52.17,,,case rate,100% of BCBS case rate,1408.62,52.17,,,case rate,100% of BCBS case rate,1408.62,52.17,,,case rate,100% of BCBS case rate,5739.25,102,,,fee schedule,Pays 102% Medicare OPPS,2430,90,,,percent of total billed charges,90% of total billed charges,945,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1854.9,68.7,,,percent of total billed charges,68.7% of total billed charges,2160,80,,,percent of total billed charges,80 percent of total billed charges,5626.71,100,,,fee schedule,Pays 100% Medicare OPPS,5064.04,90,,,fee schedule,Pays 90% Medicare OPPS,1566,58,,,percent of total billed charges,58% of total billed charges,549.99,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5818.09,100,,,fee schedule,Pays 100% Medicare OPPS,7563.51,130,,,fee schedule,Pays 130% Medicare OPPS,2295,85,,,percent of total billed charges,85% of total billed charges,5626.71,100,,,fee schedule,Pays 100% Medicare OPPS,549.99,7563.51,
US COMP PSEUDOANURYS GUI,4676936,CDM,402,RC,76936,HCPCS,Outpatient,,,2725,2180,,2316.25,85,,,percent of total billed charges,85% of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,320.22,130,,,fee schedule,Pays 130% Medicare OPPS,555.08,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1539.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1539.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1539.63,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1531.45,56.5,,,percent of total billed charges,56.5 percent of total billed charges,242.49,102,,,fee schedule,Pays 102% Medicare OPPS,2452.5,90,,,percent of total billed charges,90% of total billed charges,953.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1872.08,68.7,,,percent of total billed charges,68.7% of total billed charges,2180,80,,,percent of total billed charges,80 percent of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,213.96,90,,,fee schedule,Pays 90% Medicare OPPS,1580.5,58,,,percent of total billed charges,58% of total billed charges,555.08,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,246.33,100,,,fee schedule,Pays 100% Medicare OPPS,320.22,130,,,fee schedule,Pays 130% Medicare OPPS,2316.25,85,,,percent of total billed charges,85% of total billed charges,237.74,100,,,fee schedule,Pays 100% Medicare OPPS,213.96,2452.5,
FIXATION SYSTEM OPTIFIX OPEN 0113320,7950128,CDM,272,RC,,,Outpatient,,,2745,2196,,2333.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,559.16,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1550.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1550.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1550.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1550.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,2470.5,90,,,percent of total billed charges,90% of total billed charges,960.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1885.82,68.7,,,percent of total billed charges,68.7% of total billed charges,2196,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1592.1,58,,,percent of total billed charges,58% of total billed charges,559.16,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2333.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,559.16,2470.5,
FIXATION DEVICE SORBAFIX 0113116,7950154,CDM,272,RC,,,Outpatient,,,2745,2196,,2333.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,559.16,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1550.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1550.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1550.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1550.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,2470.5,90,,,percent of total billed charges,90% of total billed charges,960.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1885.82,68.7,,,percent of total billed charges,68.7% of total billed charges,2196,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1592.1,58,,,percent of total billed charges,58% of total billed charges,559.16,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2333.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,559.16,2470.5,
FIXATION SYSTEM OPTIFIX AT 0113330,7950160,CDM,272,RC,,,Outpatient,,,2745,2196,,2333.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,559.16,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1550.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1550.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1550.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1550.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,2470.5,90,,,percent of total billed charges,90% of total billed charges,960.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1885.82,68.7,,,percent of total billed charges,68.7% of total billed charges,2196,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1592.1,58,,,percent of total billed charges,58% of total billed charges,559.16,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2333.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,559.16,2470.5,
"Incision and drainage of hematoma, seroma or fluid collection",2010140,CDM,450,RC,10140,HCPCS,Outpatient,,,2760,2208,,2346,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,562.21,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1559.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1559.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1559.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1559.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1289.21,102,,,fee schedule,Pays 102% Medicare OPPS,2484,90,,,percent of total billed charges,90% of total billed charges,966,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1896.12,68.7,,,percent of total billed charges,68.7% of total billed charges,2208,80,,,percent of total billed charges,80 percent of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1137.55,90,,,fee schedule,Pays 90% Medicare OPPS,1600.8,58,,,percent of total billed charges,58% of total billed charges,562.21,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1318.97,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,2346,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,562.21,2484,
CHOLECYSTECTOMY TRAY TNC61XL,7950147,CDM,272,RC,,,Outpatient,,,2760,2208,,2346,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,562.21,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1559.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1559.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1559.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1559.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,2484,90,,,percent of total billed charges,90% of total billed charges,966,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1896.12,68.7,,,percent of total billed charges,68.7% of total billed charges,2208,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1600.8,58,,,percent of total billed charges,58% of total billed charges,562.21,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2346,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,562.21,2484,
VAGINAL DELIVERY,4002310,CDM,720,RC,,,Outpatient,,,2770,2216,,2354.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,564.25,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1565.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1565.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1565.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1565.05,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,2493,90,,,percent of total billed charges,90% of total billed charges,969.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1902.99,68.7,,,percent of total billed charges,68.7% of total billed charges,2216,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1606.6,58,,,percent of total billed charges,58% of total billed charges,564.25,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2354.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,564.25,2493,
HERNIA PATCH,1570005,CDM,278,RC,C1781,HCPCS,Both,,,2785,2228,,2367.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,567.3,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1452.96,52.17,,,case rate,100% of BCBS case rate,1452.96,52.17,,,case rate,100% of BCBS case rate,1452.96,52.17,,,case rate,100% of BCBS case rate,1452.96,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,2506.5,90,,,percent of total billed charges,90% of total billed charges,974.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1913.3,68.7,,,percent of total billed charges,68.7% of total billed charges,2228,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1615.3,58,,,percent of total billed charges,58% of total billed charges,567.3,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2367.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,567.3,2506.5,
HERNIA PATCH,7950083,CDM,278,RC,C1781,HCPCS,Both,,,2785,2228,,2367.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,567.3,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1452.96,52.17,,,case rate,100% of BCBS case rate,1452.96,52.17,,,case rate,100% of BCBS case rate,1452.96,52.17,,,case rate,100% of BCBS case rate,1452.96,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,2506.5,90,,,percent of total billed charges,90% of total billed charges,974.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1913.3,68.7,,,percent of total billed charges,68.7% of total billed charges,2228,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1615.3,58,,,percent of total billed charges,58% of total billed charges,567.3,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2367.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,567.3,2506.5,
REMOVAL SUBQ RHYTHM MNTR,1533286,CDM,360,RC,33286,HCPCS,Outpatient,,,2815,2252,,2392.75,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,742.06,130,,,fee schedule,Pays 130% Medicare ,573.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,570.18,102,,,fee schedule,Pays 102% Medicare OPPS,2533.5,90,,,percent of total billed charges,90% of total billed charges,985.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1933.91,68.7,,,percent of total billed charges,68.7% of total billed charges,2252,80,,,percent of total billed charges,80 percent of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,503.1,90,,,fee schedule,Pays 90% Medicare OPPS,1632.7,58,,,percent of total billed charges,58% of total billed charges,573.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,570.82,100,,,fee schedule,Pays 100% Medicare OPPS,742.06,130,,,fee schedule,Pays 130% Medicare ,2392.75,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,503.1,2533.5,
"Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function",5793306,CDM,483,RC,93306,HCPCS,Outpatient,,,2825,2260,,2401.25,85,,,percent of total billed charges,85% of total billed charges,434.05,100,,,fee schedule,Pays 100% Medicare OPPS,434.05,100,,,fee schedule,Pays 100% Medicare OPPS,434.05,100,,,fee schedule,Pays 100% Medicare OPPS,575.29,130,,,fee schedule,Pays 130% Medicare OPPS,575.45,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,442.72,102,,,fee schedule,Pays 102% Medicare OPPS,2542.5,90,,,percent of total billed charges,90% of total billed charges,988.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1940.78,68.7,,,percent of total billed charges,68.7% of total billed charges,2260,80,,,percent of total billed charges,80 percent of total billed charges,434.05,100,,,fee schedule,Pays 100% Medicare OPPS,390.64,90,,,fee schedule,Pays 90% Medicare OPPS,1638.5,58,,,percent of total billed charges,58% of total billed charges,575.45,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,442.54,100,,,fee schedule,Pays 100% Medicare OPPS,575.29,130,,,fee schedule,Pays 130% Medicare OPPS,2401.25,85,,,percent of total billed charges,85% of total billed charges,434.05,100,,,fee schedule,Pays 100% Medicare OPPS,390.64,2542.5,
BRACE TAYLOR KNIGHT,7907173,CDM,274,RC,L0468,HCPCS,Both,,,2850,2280,,2422.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,580.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1486.87,52.17,,,case rate,100% of BCBS case rate,1486.87,52.17,,,case rate,100% of BCBS case rate,1486.87,52.17,,,case rate,100% of BCBS case rate,1486.87,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,2565,90,,,percent of total billed charges,90% of total billed charges,997.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1957.95,68.7,,,percent of total billed charges,68.7% of total billed charges,2280,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1653,58,,,percent of total billed charges,58% of total billed charges,580.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2422.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,580.55,2565,
MAGTRACE 2ML VIAL INJ,2610526,CDM,270,RC,,,Outpatient,,,2875,2300,,2443.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,585.64,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1624.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1624.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1624.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1624.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,2587.5,90,,,percent of total billed charges,90% of total billed charges,1006.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1975.13,68.7,,,percent of total billed charges,68.7% of total billed charges,2300,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1667.5,58,,,percent of total billed charges,58% of total billed charges,585.64,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2443.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,585.64,2587.5,
HERNIA ECHO 2 POSITIONING SYSTEM 5990011,1570381,CDM,278,RC,C1781,HCPCS,Both,,,2895,2316,,2460.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,589.71,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1510.35,52.17,,,case rate,100% of BCBS case rate,1510.35,52.17,,,case rate,100% of BCBS case rate,1510.35,52.17,,,case rate,100% of BCBS case rate,1510.35,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,2605.5,90,,,percent of total billed charges,90% of total billed charges,1013.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1988.87,68.7,,,percent of total billed charges,68.7% of total billed charges,2316,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1679.1,58,,,percent of total billed charges,58% of total billed charges,589.71,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2460.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,589.71,2605.5,
DRAIN FINGER ABSC COMPLICATED,2026011,CDM,450,RC,26011,HCPCS,Outpatient,,,2900,2320,,2465,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,590.73,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1638.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1638.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1638.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1638.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1289.21,102,,,fee schedule,Pays 102% Medicare OPPS,2610,90,,,percent of total billed charges,90% of total billed charges,1015,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1992.3,68.7,,,percent of total billed charges,68.7% of total billed charges,2320,80,,,percent of total billed charges,80 percent of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1137.55,90,,,fee schedule,Pays 90% Medicare OPPS,1682,58,,,percent of total billed charges,58% of total billed charges,590.73,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1318.97,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,2465,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,590.73,2610,
CLOSED TREATMENT OF PATELLAR DISLOCATION,2027562,CDM,450,RC,27562,HCPCS,Outpatient,,,2900,2320,,2465,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,590.73,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1638.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1638.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1638.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1638.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,188.85,102,,,fee schedule,Pays 102% Medicare OPPS,2610,90,,,percent of total billed charges,90% of total billed charges,1015,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,1992.3,68.7,,,percent of total billed charges,68.7% of total billed charges,2320,80,,,percent of total billed charges,80 percent of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,166.63,90,,,fee schedule,Pays 90% Medicare OPPS,1682,58,,,percent of total billed charges,58% of total billed charges,590.73,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,182.08,100,,,fee schedule,Pays 100% Medicare OPPS,236.7,130,,,fee schedule,Pays 130% Medicare OPPS,2465,85,,,percent of total billed charges,85% of total billed charges,185.15,100,,,fee schedule,Pays 100% Medicare OPPS,166.63,2610,
EGD ESOPHOGASTRODUODNOSCO,1703000,CDM,750,RC,,,Outpatient,,,2920,2336,,2482,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,594.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1649.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1649.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1649.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1649.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,2628,90,,,percent of total billed charges,90% of total billed charges,1022,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2006.04,68.7,,,percent of total billed charges,68.7% of total billed charges,2336,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1693.6,58,,,percent of total billed charges,58% of total billed charges,594.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2482,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,594.8,2628,
SIGMOIDOSCOPY FLEXIBLE,1703003,CDM,750,RC,,,Outpatient,,,2920,2336,,2482,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,594.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1649.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1649.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1649.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1649.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,2628,90,,,percent of total billed charges,90% of total billed charges,1022,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2006.04,68.7,,,percent of total billed charges,68.7% of total billed charges,2336,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1693.6,58,,,percent of total billed charges,58% of total billed charges,594.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2482,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,594.8,2628,
EGD W/ RMVL OF PLYP TUMOR,1703020,CDM,750,RC,,,Outpatient,,,2920,2336,,2482,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,594.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1649.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1649.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1649.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1649.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,2628,90,,,percent of total billed charges,90% of total billed charges,1022,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2006.04,68.7,,,percent of total billed charges,68.7% of total billed charges,2336,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1693.6,58,,,percent of total billed charges,58% of total billed charges,594.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2482,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,594.8,2628,
CT LIMITED/LOCALIZED STUD,4276380,CDM,350,RC,76380,HCPCS,Outpatient,,,2950,2360,,2507.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,600.92,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1666.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1666.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1666.75,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1657.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,2655,90,,,percent of total billed charges,90% of total billed charges,1032.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2026.65,68.7,,,percent of total billed charges,68.7% of total billed charges,2360,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,1711,58,,,percent of total billed charges,58% of total billed charges,600.92,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,2507.5,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,2655,
REPAIR KIT TIGHTROPE SYNDESMOSIS,1570171,CDM,278,RC,,,Both,,,2965,2372,,2520.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,603.97,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1546.87,52.17,,,case rate,100% of BCBS case rate,1546.87,52.17,,,case rate,100% of BCBS case rate,1546.87,52.17,,,case rate,100% of BCBS case rate,1546.87,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,2668.5,90,,,percent of total billed charges,90% of total billed charges,1037.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2036.96,68.7,,,percent of total billed charges,68.7% of total billed charges,2372,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1719.7,58,,,percent of total billed charges,58% of total billed charges,603.97,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2520.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,603.97,2668.5,
CL TX TRIMALL ANKLE FX W MANIP,2027818,CDM,450,RC,27818,HCPCS,Outpatient,,,2985,2388,,2537.25,85,,,percent of total billed charges,85% of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1640.3,130,,,fee schedule,Pays 130% Medicare OPPS,608.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1686.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1686.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1686.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1686.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1276.23,102,,,fee schedule,Pays 102% Medicare OPPS,2686.5,90,,,percent of total billed charges,90% of total billed charges,1044.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2050.7,68.7,,,percent of total billed charges,68.7% of total billed charges,2388,80,,,percent of total billed charges,80 percent of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1126.08,90,,,fee schedule,Pays 90% Medicare OPPS,1731.3,58,,,percent of total billed charges,58% of total billed charges,608.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1261.77,100,,,fee schedule,Pays 100% Medicare OPPS,1640.3,130,,,fee schedule,Pays 130% Medicare OPPS,2537.25,85,,,percent of total billed charges,85% of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,608.04,2686.5,
HERNIA PATCH VENTRALEX ST 8CM 5950009,1570058,CDM,278,RC,C1781,HCPCS,Both,,,2995,2396,,2545.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,610.08,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1562.52,52.17,,,case rate,100% of BCBS case rate,1562.52,52.17,,,case rate,100% of BCBS case rate,1562.52,52.17,,,case rate,100% of BCBS case rate,1562.52,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,2695.5,90,,,percent of total billed charges,90% of total billed charges,1048.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2057.57,68.7,,,percent of total billed charges,68.7% of total billed charges,2396,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1737.1,58,,,percent of total billed charges,58% of total billed charges,610.08,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2545.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,610.08,2695.5,
BB CONVALESCENT PLASMA UNIT,3109018,CDM,390,RC,P9017,HCPCS,Outpatient,,,3000,2400,,2550,85,,,percent of total billed charges,85% of total billed charges,84.4,100,,,fee schedule,Pays 100% Medicare OPPS,84.4,100,,,fee schedule,Pays 100% Medicare OPPS,84.4,100,,,fee schedule,Pays 100% Medicare OPPS,111.11,130,,,fee schedule,Pays 130% Medicare OPPS,611.1,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1695,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1695,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1695,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1695,56.5,,,percent of total billed charges,56.5 percent of total billed charges,86.08,102,,,fee schedule,Pays 102% Medicare OPPS,2700,90,,,percent of total billed charges,90% of total billed charges,1050,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2061,68.7,,,percent of total billed charges,68.7% of total billed charges,2400,80,,,percent of total billed charges,80 percent of total billed charges,84.4,100,,,fee schedule,Pays 100% Medicare OPPS,75.95,90,,,fee schedule,Pays 90% Medicare OPPS,1740,58,,,percent of total billed charges,58% of total billed charges,611.1,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,85.47,100,,,fee schedule,Pays 100% Medicare OPPS,111.11,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,84.4,100,,,fee schedule,Pays 100% Medicare OPPS,75.95,2700,
TRACHEOSTOMY,3031603,CDM,450,RC,31603,HCPCS,Outpatient,,,3025,2420,,2571.25,85,,,percent of total billed charges,85% of total billed charges,1215.17,100,,,fee schedule,Pays 100% Medicare OPPS,1215.17,100,,,fee schedule,Pays 100% Medicare OPPS,1215.17,100,,,fee schedule,Pays 100% Medicare OPPS,1587.27,130,,,fee schedule,Pays 130% Medicare OPPS,616.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1709.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1709.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1709.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1709.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1239.47,102,,,fee schedule,Pays 102% Medicare OPPS,2722.5,90,,,percent of total billed charges,90% of total billed charges,1058.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2078.18,68.7,,,percent of total billed charges,68.7% of total billed charges,2420,80,,,percent of total billed charges,80 percent of total billed charges,1215.17,100,,,fee schedule,Pays 100% Medicare OPPS,1093.65,90,,,fee schedule,Pays 90% Medicare OPPS,1754.5,58,,,percent of total billed charges,58% of total billed charges,616.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1220.98,100,,,fee schedule,Pays 100% Medicare OPPS,1587.27,130,,,fee schedule,Pays 130% Medicare OPPS,2571.25,85,,,percent of total billed charges,85% of total billed charges,1215.17,100,,,fee schedule,Pays 100% Medicare OPPS,616.19,2722.5,
NM MYOCARDIAL SPECT SINGLE S,4578464,CDM,341,RC,78451,HCPCS,Outpatient,,,3025,2420,,2571.25,85,,,percent of total billed charges,85% of total billed charges,1173.9,100,,,fee schedule,Pays 100% Medicare OPPS,1173.9,100,,,fee schedule,Pays 100% Medicare OPPS,1173.9,100,,,fee schedule,Pays 100% Medicare OPPS,1517.67,130,,,fee schedule,Pays 130% Medicare ,616.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1709.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1709.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1709.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1709.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1197.38,102,,,fee schedule,Pays 102% Medicare OPPS,2722.5,90,,,percent of total billed charges,90% of total billed charges,1058.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2078.18,68.7,,,percent of total billed charges,68.7% of total billed charges,2420,80,,,percent of total billed charges,80 percent of total billed charges,1173.9,100,,,fee schedule,Pays 100% Medicare OPPS,1056.5,90,,,fee schedule,Pays 90% Medicare OPPS,1754.5,58,,,percent of total billed charges,58% of total billed charges,616.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1167.44,100,,,fee schedule,Pays 100% Medicare OPPS,1517.67,130,,,fee schedule,Pays 130% Medicare ,2571.25,85,,,percent of total billed charges,85% of total billed charges,1173.9,100,,,fee schedule,Pays 100% Medicare OPPS,616.19,2722.5,
Image of the heart to assess perfusion,4578465,CDM,341,RC,78452,HCPCS,Outpatient,,,3025,2420,,2571.25,85,,,percent of total billed charges,85% of total billed charges,1173.9,100,,,fee schedule,Pays 100% Medicare OPPS,1173.9,100,,,fee schedule,Pays 100% Medicare OPPS,1173.9,100,,,fee schedule,Pays 100% Medicare OPPS,1517.67,130,,,fee schedule,Pays 130% Medicare OPPS,616.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1709.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1709.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1709.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1709.13,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1197.38,102,,,fee schedule,Pays 102% Medicare OPPS,2722.5,90,,,percent of total billed charges,90% of total billed charges,1058.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2078.18,68.7,,,percent of total billed charges,68.7% of total billed charges,2420,80,,,percent of total billed charges,80 percent of total billed charges,1173.9,100,,,fee schedule,Pays 100% Medicare OPPS,1056.5,90,,,fee schedule,Pays 90% Medicare OPPS,1754.5,58,,,percent of total billed charges,58% of total billed charges,616.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1167.44,100,,,fee schedule,Pays 100% Medicare OPPS,1517.67,130,,,fee schedule,Pays 130% Medicare OPPS,2571.25,85,,,percent of total billed charges,85% of total billed charges,1173.9,100,,,fee schedule,Pays 100% Medicare OPPS,616.19,2722.5,
PLATE VLP 2.7MM MTP,1570360,CDM,278,RC,A4649,HCPCS,Both,,,3040,2432,,2584,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,619.25,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1586,52.17,,,case rate,100% of BCBS case rate,1586,52.17,,,case rate,100% of BCBS case rate,1586,52.17,,,case rate,100% of BCBS case rate,1586,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,2736,90,,,percent of total billed charges,90% of total billed charges,1064,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2088.48,68.7,,,percent of total billed charges,68.7% of total billed charges,2432,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1763.2,58,,,percent of total billed charges,58% of total billed charges,619.25,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2584,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,619.25,2736,
GELPORT LAPAROSCOPIC SYSTEM C8XX2,1570080,CDM,272,RC,,,Outpatient,,,3090,2472,,2626.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,629.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1745.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1745.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1745.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1745.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,2781,90,,,percent of total billed charges,90% of total billed charges,1081.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2122.83,68.7,,,percent of total billed charges,68.7% of total billed charges,2472,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1792.2,58,,,percent of total billed charges,58% of total billed charges,629.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2626.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,629.43,2781,
OSTEOSET MINI BEADS,1570065,CDM,278,RC,C1713,HCPCS,Both,,,3110,2488,,2643.5,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,633.51,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1622.52,52.17,,,case rate,100% of BCBS case rate,1622.52,52.17,,,case rate,100% of BCBS case rate,1622.52,52.17,,,case rate,100% of BCBS case rate,1622.52,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,2799,90,,,percent of total billed charges,90% of total billed charges,1088.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2136.57,68.7,,,percent of total billed charges,68.7% of total billed charges,2488,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1803.8,58,,,percent of total billed charges,58% of total billed charges,633.51,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2643.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,633.51,2799,
COLONOSCOPY SCREENING,1703018,CDM,750,RC,,,Outpatient,,,3120,2496,,2652,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,635.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1762.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1762.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1762.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1762.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,2808,90,,,percent of total billed charges,90% of total billed charges,1092,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2143.44,68.7,,,percent of total billed charges,68.7% of total billed charges,2496,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1809.6,58,,,percent of total billed charges,58% of total billed charges,635.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2652,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,635.54,2808,
HERNIA COMPOSIX E/X MESH 0123680,1570046,CDM,278,RC,C1781,HCPCS,Both,,,3145,2516,,2673.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,640.64,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1640.78,52.17,,,case rate,100% of BCBS case rate,1640.78,52.17,,,case rate,100% of BCBS case rate,1640.78,52.17,,,case rate,100% of BCBS case rate,1640.78,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,2830.5,90,,,percent of total billed charges,90% of total billed charges,1100.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2160.62,68.7,,,percent of total billed charges,68.7% of total billed charges,2516,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1824.1,58,,,percent of total billed charges,58% of total billed charges,640.64,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2673.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,640.64,2830.5,
HERNIA COMPOSIX L/P MESH 0134680,1570047,CDM,278,RC,C1781,HCPCS,Both,,,3145,2516,,2673.25,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,640.64,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1640.78,52.17,,,case rate,100% of BCBS case rate,1640.78,52.17,,,case rate,100% of BCBS case rate,1640.78,52.17,,,case rate,100% of BCBS case rate,1640.78,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,2830.5,90,,,percent of total billed charges,90% of total billed charges,1100.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2160.62,68.7,,,percent of total billed charges,68.7% of total billed charges,2516,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1824.1,58,,,percent of total billed charges,58% of total billed charges,640.64,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2673.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,640.64,2830.5,
EPISIOTOMY/VAGINAL REPAIR,2059300,CDM,450,RC,59300,HCPCS,Outpatient,,,3200,2560,,2720,85,,,percent of total billed charges,85% of total billed charges,2356.88,100,,,fee schedule,Pays 100% Medicare OPPS,2356.88,100,,,fee schedule,Pays 100% Medicare OPPS,2356.88,100,,,fee schedule,Pays 100% Medicare OPPS,3233.04,130,,,fee schedule,Pays 130% Medicare OPPS,651.84,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1808,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1808,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1808,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1808,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2404.02,102,,,fee schedule,Pays 102% Medicare OPPS,2880,90,,,percent of total billed charges,90% of total billed charges,1120,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2198.4,68.7,,,percent of total billed charges,68.7% of total billed charges,2560,80,,,percent of total billed charges,80 percent of total billed charges,2356.88,100,,,fee schedule,Pays 100% Medicare OPPS,2121.19,90,,,fee schedule,Pays 90% Medicare OPPS,1856,58,,,percent of total billed charges,58% of total billed charges,651.84,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2486.96,100,,,fee schedule,Pays 100% Medicare OPPS,3233.04,130,,,fee schedule,Pays 130% Medicare OPPS,2720,85,,,percent of total billed charges,85% of total billed charges,2356.88,100,,,fee schedule,Pays 100% Medicare OPPS,651.84,3233.04,
SINUS BALLOON CATHETER 5MM RELIEVA,1570753,CDM,272,RC,,,Outpatient,,,3215,2572,,2732.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,2893.5,90,,,percent of total billed charges,90% of total billed charges,1125.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2208.71,68.7,,,percent of total billed charges,68.7% of total billed charges,2572,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1864.7,58,,,percent of total billed charges,58% of total billed charges,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2732.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,654.9,2893.5,
SINUS BALLOON CATHETER 7MM RELIEVA,1570754,CDM,272,RC,,,Outpatient,,,3215,2572,,2732.75,85,,,percent of total billed charges,85% of total billed charges,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,100,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,2893.5,90,,,percent of total billed charges,90% of total billed charges,1125.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2208.71,68.7,,,percent of total billed charges,68.7% of total billed charges,2572,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,,90,,,other,Not reimbursable per contract,1864.7,58,,,percent of total billed charges,58% of total billed charges,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2732.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,654.9,2893.5,
INSERTION OF CHEST TUBE,2032551,CDM,450,RC,32551,HCPCS,Outpatient,,,3215,2572,,2732.75,85,,,percent of total billed charges,85% of total billed charges,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,1701.28,130,,,fee schedule,Pays 130% Medicare OPPS,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1288.48,102,,,fee schedule,Pays 102% Medicare OPPS,2893.5,90,,,percent of total billed charges,90% of total billed charges,1125.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2208.71,68.7,,,percent of total billed charges,68.7% of total billed charges,2572,80,,,percent of total billed charges,80 percent of total billed charges,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,1136.89,90,,,fee schedule,Pays 90% Medicare OPPS,1864.7,58,,,percent of total billed charges,58% of total billed charges,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1308.68,100,,,fee schedule,Pays 100% Medicare OPPS,1701.28,130,,,fee schedule,Pays 130% Medicare OPPS,2732.75,85,,,percent of total billed charges,85% of total billed charges,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,654.9,2893.5,
CT scan of the thorax without dye,4200001,CDM,352,RC,71250,HCPCS,Outpatient,,,3215,2572,,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1806.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,2893.5,90,,,percent of total billed charges,90% of total billed charges,1125.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2208.71,68.7,,,percent of total billed charges,68.7% of total billed charges,2572,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,1864.7,58,,,percent of total billed charges,58% of total billed charges,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,2893.5,
CT UPPER EXT W/O-LEFT,4200005,CDM,352,RC,73200,HCPCS,Outpatient,,,3215,2572,,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1806.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,2893.5,90,,,percent of total billed charges,90% of total billed charges,1125.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2208.71,68.7,,,percent of total billed charges,68.7% of total billed charges,2572,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,1864.7,58,,,percent of total billed charges,58% of total billed charges,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,2893.5,
CT DORSAL SPN W/O CONTRAS,4200012,CDM,352,RC,72128,HCPCS,Outpatient,,,3215,2572,,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1806.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,2893.5,90,,,percent of total billed charges,90% of total billed charges,1125.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2208.71,68.7,,,percent of total billed charges,68.7% of total billed charges,2572,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,1864.7,58,,,percent of total billed charges,58% of total billed charges,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,2893.5,
CT scan head or brain without dye,4270450,CDM,351,RC,70450,HCPCS,Outpatient,,,3215,2572,,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1806.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,2893.5,90,,,percent of total billed charges,90% of total billed charges,1125.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2208.71,68.7,,,percent of total billed charges,68.7% of total billed charges,2572,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,1864.7,58,,,percent of total billed charges,58% of total billed charges,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,2893.5,
CT ORBITS W/O,4270480,CDM,351,RC,70480,HCPCS,Outpatient,,,3215,2572,,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1806.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,2893.5,90,,,percent of total billed charges,90% of total billed charges,1125.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2208.71,68.7,,,percent of total billed charges,68.7% of total billed charges,2572,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,1864.7,58,,,percent of total billed charges,58% of total billed charges,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,2893.5,
CT Scan of the face and jaw without dye,4270486,CDM,351,RC,70486,HCPCS,Outpatient,,,3215,2572,,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1806.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,2893.5,90,,,percent of total billed charges,90% of total billed charges,1125.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2208.71,68.7,,,percent of total billed charges,68.7% of total billed charges,2572,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,1864.7,58,,,percent of total billed charges,58% of total billed charges,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,2893.5,
CT SOFT TISSUE NECK WO,4270490,CDM,351,RC,70490,HCPCS,Outpatient,,,3215,2572,,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1806.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,2893.5,90,,,percent of total billed charges,90% of total billed charges,1125.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2208.71,68.7,,,percent of total billed charges,68.7% of total billed charges,2572,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,1864.7,58,,,percent of total billed charges,58% of total billed charges,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,2893.5,
CT scan of the thorax without dye,4271250,CDM,352,RC,71250,HCPCS,Outpatient,,,3215,2572,,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1806.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,2893.5,90,,,percent of total billed charges,90% of total billed charges,1125.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2208.71,68.7,,,percent of total billed charges,68.7% of total billed charges,2572,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,1864.7,58,,,percent of total billed charges,58% of total billed charges,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,2893.5,
CT CERVICAL SPINE W/OUT CONTRAST,4272125,CDM,352,RC,72125,HCPCS,Outpatient,,,3215,2572,,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1806.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,2893.5,90,,,percent of total billed charges,90% of total billed charges,1125.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2208.71,68.7,,,percent of total billed charges,68.7% of total billed charges,2572,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,1864.7,58,,,percent of total billed charges,58% of total billed charges,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,2893.5,
CT THORACIC SPINE W/O,4272128,CDM,352,RC,72128,HCPCS,Outpatient,,,3215,2572,,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1806.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,2893.5,90,,,percent of total billed charges,90% of total billed charges,1125.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2208.71,68.7,,,percent of total billed charges,68.7% of total billed charges,2572,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,1864.7,58,,,percent of total billed charges,58% of total billed charges,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,2893.5,
CT scan of lower spine without dye,4272131,CDM,352,RC,72131,HCPCS,Outpatient,,,3215,2572,,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1806.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,2893.5,90,,,percent of total billed charges,90% of total billed charges,1125.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2208.71,68.7,,,percent of total billed charges,68.7% of total billed charges,2572,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,1864.7,58,,,percent of total billed charges,58% of total billed charges,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,2893.5,
CT of pelvis without dye,4272192,CDM,352,RC,72192,HCPCS,Outpatient,,,3215,2572,,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1806.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,2893.5,90,,,percent of total billed charges,90% of total billed charges,1125.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2208.71,68.7,,,percent of total billed charges,68.7% of total billed charges,2572,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,1864.7,58,,,percent of total billed charges,58% of total billed charges,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,2893.5,
CT scan of leg without dye,4272703,CDM,352,RC,73700,HCPCS,Outpatient,,,3215,2572,,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1806.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,2893.5,90,,,percent of total billed charges,90% of total billed charges,1125.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2208.71,68.7,,,percent of total billed charges,68.7% of total billed charges,2572,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,1864.7,58,,,percent of total billed charges,58% of total billed charges,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,2893.5,
CT UPPER EXT W/O-RIGHT,4273200,CDM,352,RC,73200,HCPCS,Outpatient,,,3215,2572,,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1806.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,2893.5,90,,,percent of total billed charges,90% of total billed charges,1125.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2208.71,68.7,,,percent of total billed charges,68.7% of total billed charges,2572,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,1864.7,58,,,percent of total billed charges,58% of total billed charges,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,2893.5,
CT scan of leg without dye,4273700,CDM,352,RC,73700,HCPCS,Outpatient,,,3215,2572,,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1806.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,2893.5,90,,,percent of total billed charges,90% of total billed charges,1125.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2208.71,68.7,,,percent of total billed charges,68.7% of total billed charges,2572,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,1864.7,58,,,percent of total billed charges,58% of total billed charges,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,2732.75,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,2893.5,
CT UNLISTED DIAG CT PROCEDUR,4276497,CDM,350,RC,76497,HCPCS,Outpatient,,,3215,2572,,2732.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1816.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1806.83,56.5,,,percent of total billed charges,56.5 percent of total billed charges,74.11,102,,,fee schedule,Pays 102% Medicare OPPS,2893.5,90,,,percent of total billed charges,90% of total billed charges,1125.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2208.71,68.7,,,percent of total billed charges,68.7% of total billed charges,2572,80,,,percent of total billed charges,80 percent of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,90,,,fee schedule,Pays 90% Medicare OPPS,1864.7,58,,,percent of total billed charges,58% of total billed charges,654.9,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,76.41,100,,,fee schedule,Pays 100% Medicare OPPS,99.34,130,,,fee schedule,Pays 130% Medicare OPPS,2732.75,85,,,percent of total billed charges,85% of total billed charges,72.66,100,,,fee schedule,Pays 100% Medicare OPPS,65.39,2893.5,
CT of abdomen without dye,4274151,CDM,352,RC,74150,HCPCS,Outpatient,,,3245,2596,,2758.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,661.01,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1833.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1833.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1833.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1823.69,56.5,,,percent of total billed charges,56.5 percent of total billed charges,99.75,102,,,fee schedule,Pays 102% Medicare OPPS,2920.5,90,,,percent of total billed charges,90% of total billed charges,1135.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2229.32,68.7,,,percent of total billed charges,68.7% of total billed charges,2596,80,,,percent of total billed charges,80 percent of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,90,,,fee schedule,Pays 90% Medicare OPPS,1882.1,58,,,percent of total billed charges,58% of total billed charges,661.01,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,94.01,100,,,fee schedule,Pays 100% Medicare OPPS,122.2,130,,,fee schedule,Pays 130% Medicare OPPS,2758.25,85,,,percent of total billed charges,85% of total billed charges,97.8,100,,,fee schedule,Pays 100% Medicare OPPS,88.01,2920.5,
ANOSCOPY;W OR W/O SPECIME,1703111,CDM,750,RC,46600,HCPCS,Outpatient,,,3250,2600,,2762.5,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,103.31,102,,,fee schedule,Pays 102% Medicare OPPS,2925,90,,,percent of total billed charges,90% of total billed charges,1137.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2232.75,68.7,,,percent of total billed charges,68.7% of total billed charges,2600,80,,,percent of total billed charges,80 percent of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,90,,,fee schedule,Pays 90% Medicare OPPS,1885,58,,,percent of total billed charges,58% of total billed charges,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,102.12,100,,,fee schedule,Pays 100% Medicare OPPS,132.76,130,,,fee schedule,Pays 130% Medicare OPPS,2762.5,85,,,percent of total billed charges,85% of total billed charges,101.29,100,,,fee schedule,Pays 100% Medicare OPPS,91.16,2925,
HEMORRHOID BANDING,1746945,CDM,750,RC,,,Outpatient,,,3250,2600,,2762.5,85,,,percent of total billed charges,85% of total billed charges,812.5,100,,,fee schedule,Pays 100% Medicare OPPS,812.5,100,,,fee schedule,Pays 100% Medicare OPPS,812.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,2925,90,,,percent of total billed charges,90% of total billed charges,1137.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2232.75,68.7,,,percent of total billed charges,68.7% of total billed charges,2600,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,2925,90,,,fee schedule,Pays 90% Medicare OPPS,1885,58,,,percent of total billed charges,58% of total billed charges,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2762.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,662.03,2925,
ANES INJ EPID BLOOD CLOT,1862273,CDM,379,RC,62273,HCPCS,Outpatient,,,3250,2600,,2762.5,85,,,percent of total billed charges,85% of total billed charges,570.41,100,,,fee schedule,Pays 100% Medicare OPPS,570.41,100,,,fee schedule,Pays 100% Medicare OPPS,570.41,100,,,fee schedule,Pays 100% Medicare OPPS,736.77,130,,,fee schedule,Pays 130% Medicare OPPS,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,581.83,102,,,fee schedule,Pays 102% Medicare OPPS,2925,90,,,percent of total billed charges,90% of total billed charges,1137.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2232.75,68.7,,,percent of total billed charges,68.7% of total billed charges,2600,80,,,percent of total billed charges,80 percent of total billed charges,570.41,100,,,fee schedule,Pays 100% Medicare OPPS,513.37,90,,,fee schedule,Pays 90% Medicare OPPS,1885,58,,,percent of total billed charges,58% of total billed charges,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,566.74,100,,,fee schedule,Pays 100% Medicare OPPS,736.77,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,570.41,100,,,fee schedule,Pays 100% Medicare OPPS,513.37,2925,
CT scan of the thorax with dye,4200002,CDM,352,RC,71260,HCPCS,Outpatient,,,3250,2600,,2762.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1826.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,2925,90,,,percent of total billed charges,90% of total billed charges,1137.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2232.75,68.7,,,percent of total billed charges,68.7% of total billed charges,2600,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,1885,58,,,percent of total billed charges,58% of total billed charges,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,2762.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,2925,
CT UPPER EXT W/CONT-LEFT,4200006,CDM,352,RC,73201,HCPCS,Outpatient,,,3250,2600,,2762.5,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1826.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,2925,90,,,percent of total billed charges,90% of total billed charges,1137.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2232.75,68.7,,,percent of total billed charges,68.7% of total billed charges,2600,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,1885,58,,,percent of total billed charges,58% of total billed charges,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,2762.5,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,2925,
CT LOWER EXT W/CONTR-LEFT,4200008,CDM,352,RC,73701,HCPCS,Outpatient,,,3250,2600,,2762.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1826.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,2925,90,,,percent of total billed charges,90% of total billed charges,1137.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2232.75,68.7,,,percent of total billed charges,68.7% of total billed charges,2600,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,1885,58,,,percent of total billed charges,58% of total billed charges,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,2762.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,2925,
CT DORSAL SPINE W/CON,4200013,CDM,352,RC,72129,HCPCS,Outpatient,,,3250,2600,,2762.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1826.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,2925,90,,,percent of total billed charges,90% of total billed charges,1137.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2232.75,68.7,,,percent of total billed charges,68.7% of total billed charges,2600,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,1885,58,,,percent of total billed charges,58% of total billed charges,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,2762.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,2925,
CT HEAD WITH CONTRAST,4270460,CDM,351,RC,70460,HCPCS,Outpatient,,,3250,2600,,2762.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1826.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,2925,90,,,percent of total billed charges,90% of total billed charges,1137.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2232.75,68.7,,,percent of total billed charges,68.7% of total billed charges,2600,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,1885,58,,,percent of total billed charges,58% of total billed charges,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,2762.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,2925,
CT ORBITS WITH,4270481,CDM,351,RC,70481,HCPCS,Outpatient,,,3250,2600,,2762.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1826.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,2925,90,,,percent of total billed charges,90% of total billed charges,1137.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2232.75,68.7,,,percent of total billed charges,68.7% of total billed charges,2600,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,1885,58,,,percent of total billed charges,58% of total billed charges,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,2762.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,2925,
CT MACILLO FACIAL AREA WITH,4270487,CDM,351,RC,70487,HCPCS,Outpatient,,,3250,2600,,2762.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1826.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,2925,90,,,percent of total billed charges,90% of total billed charges,1137.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2232.75,68.7,,,percent of total billed charges,68.7% of total billed charges,2600,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,1885,58,,,percent of total billed charges,58% of total billed charges,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,2762.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,2925,
CT scan of neck with dye,4270491,CDM,351,RC,70491,HCPCS,Outpatient,,,3250,2600,,2762.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1826.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,2925,90,,,percent of total billed charges,90% of total billed charges,1137.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2232.75,68.7,,,percent of total billed charges,68.7% of total billed charges,2600,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,1885,58,,,percent of total billed charges,58% of total billed charges,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,2762.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,2925,
CT scan of the thorax with dye,4271260,CDM,352,RC,71260,HCPCS,Outpatient,,,3250,2600,,2762.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1826.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,2925,90,,,percent of total billed charges,90% of total billed charges,1137.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2232.75,68.7,,,percent of total billed charges,68.7% of total billed charges,2600,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,1885,58,,,percent of total billed charges,58% of total billed charges,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,2762.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,2925,
CT LOWER EXT W/O CONTRAST LEFT,4272122,CDM,352,RC,73701,HCPCS,Outpatient,,,3250,2600,,2762.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1826.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,2925,90,,,percent of total billed charges,90% of total billed charges,1137.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2232.75,68.7,,,percent of total billed charges,68.7% of total billed charges,2600,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,1885,58,,,percent of total billed charges,58% of total billed charges,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,2762.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,2925,
CT CERVICAL SPINE W/CONTRAST,4272126,CDM,352,RC,72126,HCPCS,Outpatient,,,3250,2600,,2762.5,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1826.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,2925,90,,,percent of total billed charges,90% of total billed charges,1137.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2232.75,68.7,,,percent of total billed charges,68.7% of total billed charges,2600,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,1885,58,,,percent of total billed charges,58% of total billed charges,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,2762.5,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,2925,
CT THORACIC SPINE WITH,4272129,CDM,352,RC,72129,HCPCS,Outpatient,,,3250,2600,,2762.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1826.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,2925,90,,,percent of total billed charges,90% of total billed charges,1137.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2232.75,68.7,,,percent of total billed charges,68.7% of total billed charges,2600,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,1885,58,,,percent of total billed charges,58% of total billed charges,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,2762.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,2925,
CT LUMBAR SPINE W/CONTRAST,4272132,CDM,352,RC,72132,HCPCS,Outpatient,,,3250,2600,,2762.5,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1826.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,2925,90,,,percent of total billed charges,90% of total billed charges,1137.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2232.75,68.7,,,percent of total billed charges,68.7% of total billed charges,2600,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,1885,58,,,percent of total billed charges,58% of total billed charges,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,2762.5,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,2925,
"CT scan, pelvis, with contrast",4272193,CDM,352,RC,72193,HCPCS,Outpatient,,,3250,2600,,2762.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1826.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,2925,90,,,percent of total billed charges,90% of total billed charges,1137.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2232.75,68.7,,,percent of total billed charges,68.7% of total billed charges,2600,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,1885,58,,,percent of total billed charges,58% of total billed charges,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,2762.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,2925,
CT UPPER EXT W/CONT-RIGHT,4273201,CDM,352,RC,73201,HCPCS,Outpatient,,,3250,2600,,2762.5,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1826.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,2925,90,,,percent of total billed charges,90% of total billed charges,1137.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2232.75,68.7,,,percent of total billed charges,68.7% of total billed charges,2600,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,1885,58,,,percent of total billed charges,58% of total billed charges,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,2762.5,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,2925,
CT LOWER EXT W/CONT-RIGHT,4273701,CDM,352,RC,73701,HCPCS,Outpatient,,,3250,2600,,2762.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1826.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,2925,90,,,percent of total billed charges,90% of total billed charges,1137.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2232.75,68.7,,,percent of total billed charges,68.7% of total billed charges,2600,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,1885,58,,,percent of total billed charges,58% of total billed charges,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,2762.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,2925,
CT of abdomen with dye,4274150,CDM,352,RC,74160,HCPCS,Outpatient,,,3250,2600,,2762.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1836.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1826.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,2925,90,,,percent of total billed charges,90% of total billed charges,1137.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2232.75,68.7,,,percent of total billed charges,68.7% of total billed charges,2600,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,1885,58,,,percent of total billed charges,58% of total billed charges,662.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,2762.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,2925,
.TISSUE CULTURE(CHROM FISH,3000306,CDM,301,RC,88237,HCPCS,Outpatient,,,3300,2640,,2805,85,,,percent of total billed charges,85% of total billed charges,143.75,100,,,fee schedule,Pays 100% Medicare OPPS,143.75,100,,,fee schedule,Pays 100% Medicare OPPS,143.75,100,,,fee schedule,Pays 100% Medicare OPPS,186.87,130,APC,,fee schedule,Pays 130% Medicare OPPS,133.63,120.37,,,fee schedule,120.37% of custom fee schedule,1864.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1864.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1864.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1864.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,146.62,102,,,fee schedule,Pays 102% Medicare OPPS,2970,90,,,percent of total billed charges,90% of total billed charges,138.97,125.18,,,fee schedule,125.18% of custom fee schedule,2267.1,68.7,,,percent of total billed charges,68.7% of total billed charges,2640,80,,,percent of total billed charges,80 percent of total billed charges,143.75,100,,,fee schedule,Pays 100% Medicare OPPS,129.37,90,,,fee schedule,Pays 90% Medicare OPPS,1914,58,,,percent of total billed charges,58% of total billed charges,133.63,120.37,,,fee schedule,120.37% of custom fee schedule,143.75,100,,,fee schedule,Pays 100% Medicare OPPS,186.87,130,APC,,fee schedule,Pays 130% Medicare OPPS,2805,85,,,percent of total billed charges,85% of total billed charges,143.75,100,,,fee schedule,Pays 100% Medicare OPPS,129.37,2970,
EXCISION BENIGN LESION .5CM OR LESS,2011420,CDM,450,RC,11420,HCPCS,Outpatient,,,3315,2652,,2817.75,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,675.27,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1872.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1872.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1872.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1872.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1289.21,102,,,fee schedule,Pays 102% Medicare OPPS,2983.5,90,,,percent of total billed charges,90% of total billed charges,1160.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2277.41,68.7,,,percent of total billed charges,68.7% of total billed charges,2652,80,,,percent of total billed charges,80 percent of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1137.55,90,,,fee schedule,Pays 90% Medicare OPPS,1922.7,58,,,percent of total billed charges,58% of total billed charges,675.27,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1318.97,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,2817.75,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,675.27,2983.5,
C REP TRUNK 2.6-7.5 CM,2013101,CDM,450,RC,13101,HCPCS,Outpatient,,,3315,2652,,2817.75,85,,,percent of total billed charges,85% of total billed charges,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,664.28,130,,,fee schedule,Pays 130% Medicare OPPS,675.27,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1872.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1872.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1872.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1872.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,479.88,102,,,fee schedule,Pays 102% Medicare OPPS,2983.5,90,,,percent of total billed charges,90% of total billed charges,1160.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2277.41,68.7,,,percent of total billed charges,68.7% of total billed charges,2652,80,,,percent of total billed charges,80 percent of total billed charges,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,423.42,90,,,fee schedule,Pays 90% Medicare OPPS,1922.7,58,,,percent of total billed charges,58% of total billed charges,675.27,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,510.99,100,,,fee schedule,Pays 100% Medicare OPPS,664.28,130,,,fee schedule,Pays 130% Medicare OPPS,2817.75,85,,,percent of total billed charges,85% of total billed charges,470.47,100,,,fee schedule,Pays 100% Medicare OPPS,423.42,2983.5,
DRAINAGE OF SCROTAL WALL ABSCESS,2055100,CDM,450,RC,55100,HCPCS,Outpatient,,,3315,2652,,2817.75,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,675.27,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1872.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1872.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1872.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1872.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1289.21,102,,,fee schedule,Pays 102% Medicare OPPS,2983.5,90,,,percent of total billed charges,90% of total billed charges,1160.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2277.41,68.7,,,percent of total billed charges,68.7% of total billed charges,2652,80,,,percent of total billed charges,80 percent of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1137.55,90,,,fee schedule,Pays 90% Medicare OPPS,1922.7,58,,,percent of total billed charges,58% of total billed charges,675.27,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1318.97,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,2817.75,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,675.27,2983.5,
****DO NOT USE****,7950149,CDM,270,RC,,,Outpatient,,,3340,2672,,2839,85,,,percent of total billed charges,85% of total billed charges,835,100,,,fee schedule,Pays 100% Medicare OPPS,835,100,,,fee schedule,Pays 100% Medicare OPPS,835,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,680.36,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1887.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1887.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1887.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1887.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,3006,90,,,percent of total billed charges,90% of total billed charges,1169,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2294.58,68.7,,,percent of total billed charges,68.7% of total billed charges,2672,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,3006,90,,,fee schedule,Pays 90% Medicare OPPS,1937.2,58,,,percent of total billed charges,58% of total billed charges,680.36,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,2839,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,680.36,3006,
"Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope",1543235,CDM,360,RC,43235,HCPCS,Outpatient,,,3500,2800,,2975,85,,,percent of total billed charges,85% of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,943.93,130,,,fee schedule,Pays 130% Medicare OPPS,712.95,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,741.4,102,,,fee schedule,Pays 102% Medicare OPPS,3150,90,,,percent of total billed charges,90% of total billed charges,1225,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2404.5,68.7,,,percent of total billed charges,68.7% of total billed charges,2800,80,,,percent of total billed charges,80 percent of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,654.17,90,,,fee schedule,Pays 90% Medicare OPPS,2030,58,,,percent of total billed charges,58% of total billed charges,712.95,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,726.1,100,,,fee schedule,Pays 100% Medicare OPPS,943.93,130,,,fee schedule,Pays 130% Medicare OPPS,2975,85,,,percent of total billed charges,85% of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,654.17,3150,
UNLISTED PROCEDURE ANUS,1546999,CDM,360,RC,46999,HCPCS,Outpatient,,,3500,2800,,2975,85,,,percent of total billed charges,85% of total billed charges,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,950.25,130,,,fee schedule,Pays 130% Medicare OPPS,712.95,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,727.13,102,,,fee schedule,Pays 102% Medicare OPPS,3150,90,,,percent of total billed charges,90% of total billed charges,1225,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2404.5,68.7,,,percent of total billed charges,68.7% of total billed charges,2800,80,,,percent of total billed charges,80 percent of total billed charges,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,641.59,90,,,fee schedule,Pays 90% Medicare OPPS,2030,58,,,percent of total billed charges,58% of total billed charges,712.95,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,730.96,100,,,fee schedule,Pays 100% Medicare OPPS,950.25,130,,,fee schedule,Pays 130% Medicare OPPS,2975,85,,,percent of total billed charges,85% of total billed charges,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,641.59,3150,
PERITONEAL LAVAGE,1549084,CDM,360,RC,49084,HCPCS,Outpatient,,,3500,2800,,2975,85,,,percent of total billed charges,85% of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,943.93,130,,,fee schedule,Pays 130% Medicare OPPS,712.95,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,741.4,102,,,fee schedule,Pays 102% Medicare OPPS,3150,90,,,percent of total billed charges,90% of total billed charges,1225,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2404.5,68.7,,,percent of total billed charges,68.7% of total billed charges,2800,80,,,percent of total billed charges,80 percent of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,654.17,90,,,fee schedule,Pays 90% Medicare OPPS,2030,58,,,percent of total billed charges,58% of total billed charges,712.95,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,726.1,100,,,fee schedule,Pays 100% Medicare OPPS,943.93,130,,,fee schedule,Pays 130% Medicare OPPS,2975,85,,,percent of total billed charges,85% of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,654.17,3150,
CTA UPPER EXTREMITY W/WO,4273206,CDM,352,RC,73206,HCPCS,Outpatient,,,3540,2832,,3009,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,721.1,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2000.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2000.1,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1989.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,3186,90,,,percent of total billed charges,90% of total billed charges,1239,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2431.98,68.7,,,percent of total billed charges,68.7% of total billed charges,2832,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,2053.2,58,,,percent of total billed charges,58% of total billed charges,721.1,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,3009,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,3186,
...........................CT CHEST W/WO,4200003,CDM,352,RC,71270,HCPCS,Outpatient,,,3545,2836,,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1992.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,3190.5,90,,,percent of total billed charges,90% of total billed charges,1240.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2435.42,68.7,,,percent of total billed charges,68.7% of total billed charges,2836,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,2056.1,58,,,percent of total billed charges,58% of total billed charges,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,3190.5,
CT THORAX W/WO CONTRAST,4200004,CDM,352,RC,71270,HCPCS,Outpatient,,,3545,2836,,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1992.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,3190.5,90,,,percent of total billed charges,90% of total billed charges,1240.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2435.42,68.7,,,percent of total billed charges,68.7% of total billed charges,2836,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,2056.1,58,,,percent of total billed charges,58% of total billed charges,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,3190.5,
CT UPPER EXT W/WO LEFT,4200007,CDM,352,RC,73202,HCPCS,Outpatient,,,3545,2836,,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1992.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,3190.5,90,,,percent of total billed charges,90% of total billed charges,1240.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2435.42,68.7,,,percent of total billed charges,68.7% of total billed charges,2836,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,2056.1,58,,,percent of total billed charges,58% of total billed charges,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,3190.5,
CT LOWER EXT W/WO LEFT,4200009,CDM,352,RC,73702,HCPCS,Outpatient,,,3545,2836,,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1992.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,3190.5,90,,,percent of total billed charges,90% of total billed charges,1240.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2435.42,68.7,,,percent of total billed charges,68.7% of total billed charges,2836,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,2056.1,58,,,percent of total billed charges,58% of total billed charges,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,3190.5,
CT HEAD W & W/O CONTRAST,4270470,CDM,351,RC,70470,HCPCS,Outpatient,,,3545,2836,,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1992.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,3190.5,90,,,percent of total billed charges,90% of total billed charges,1240.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2435.42,68.7,,,percent of total billed charges,68.7% of total billed charges,2836,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,2056.1,58,,,percent of total billed charges,58% of total billed charges,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,3190.5,
CT ORBITS W/WO,4270482,CDM,351,RC,70482,HCPCS,Outpatient,,,3545,2836,,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1992.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,3190.5,90,,,percent of total billed charges,90% of total billed charges,1240.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2435.42,68.7,,,percent of total billed charges,68.7% of total billed charges,2836,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,2056.1,58,,,percent of total billed charges,58% of total billed charges,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,3190.5,
CT MAXILLO FACIAL AREA W/WO,4270488,CDM,351,RC,70488,HCPCS,Outpatient,,,3545,2836,,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1992.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,3190.5,90,,,percent of total billed charges,90% of total billed charges,1240.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2435.42,68.7,,,percent of total billed charges,68.7% of total billed charges,2836,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,2056.1,58,,,percent of total billed charges,58% of total billed charges,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,3190.5,
CT SOFT TISSUE NECK W/WO,4270492,CDM,351,RC,70492,HCPCS,Outpatient,,,3545,2836,,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1992.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,3190.5,90,,,percent of total billed charges,90% of total billed charges,1240.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2435.42,68.7,,,percent of total billed charges,68.7% of total billed charges,2836,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,2056.1,58,,,percent of total billed charges,58% of total billed charges,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,3190.5,
CT THORAX W/OUT CONTRAST,4271270,CDM,352,RC,71270,HCPCS,Outpatient,,,3545,2836,,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1992.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,3190.5,90,,,percent of total billed charges,90% of total billed charges,1240.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2435.42,68.7,,,percent of total billed charges,68.7% of total billed charges,2836,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,2056.1,58,,,percent of total billed charges,58% of total billed charges,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,3190.5,
CT DORSAL SPINE W/WO CONTRAST,4272120,CDM,352,RC,72130,HCPCS,Outpatient,,,3545,2836,,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1992.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,3190.5,90,,,percent of total billed charges,90% of total billed charges,1240.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2435.42,68.7,,,percent of total billed charges,68.7% of total billed charges,2836,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,2056.1,58,,,percent of total billed charges,58% of total billed charges,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,3190.5,
CT CERVICAL SPINE W/WO,4272127,CDM,352,RC,72127,HCPCS,Outpatient,,,3545,2836,,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1992.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,3190.5,90,,,percent of total billed charges,90% of total billed charges,1240.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2435.42,68.7,,,percent of total billed charges,68.7% of total billed charges,2836,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,2056.1,58,,,percent of total billed charges,58% of total billed charges,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,3190.5,
CT THORACIC SPINE W/WO,4272130,CDM,352,RC,72130,HCPCS,Outpatient,,,3545,2836,,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1992.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,3190.5,90,,,percent of total billed charges,90% of total billed charges,1240.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2435.42,68.7,,,percent of total billed charges,68.7% of total billed charges,2836,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,2056.1,58,,,percent of total billed charges,58% of total billed charges,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,3190.5,
CT LUMBAR SPINE W/WO,4272133,CDM,352,RC,72133,HCPCS,Outpatient,,,3545,2836,,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1992.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,3190.5,90,,,percent of total billed charges,90% of total billed charges,1240.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2435.42,68.7,,,percent of total billed charges,68.7% of total billed charges,2836,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,2056.1,58,,,percent of total billed charges,58% of total billed charges,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,3190.5,
CT PELVIS W & W/O CON,4272194,CDM,352,RC,72194,HCPCS,Outpatient,,,3545,2836,,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1992.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,3190.5,90,,,percent of total billed charges,90% of total billed charges,1240.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2435.42,68.7,,,percent of total billed charges,68.7% of total billed charges,2836,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,2056.1,58,,,percent of total billed charges,58% of total billed charges,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,3190.5,
CT UPPER EXT W&W/O-RIGHT,4273202,CDM,352,RC,73202,HCPCS,Outpatient,,,3545,2836,,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1992.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,3190.5,90,,,percent of total billed charges,90% of total billed charges,1240.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2435.42,68.7,,,percent of total billed charges,68.7% of total billed charges,2836,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,2056.1,58,,,percent of total billed charges,58% of total billed charges,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,3190.5,
CT LOWER EXT W/WO RIGHT,4273702,CDM,352,RC,73702,HCPCS,Outpatient,,,3545,2836,,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1992.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,3190.5,90,,,percent of total billed charges,90% of total billed charges,1240.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2435.42,68.7,,,percent of total billed charges,68.7% of total billed charges,2836,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,2056.1,58,,,percent of total billed charges,58% of total billed charges,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,3190.5,
CT DORSAL SPINE,4273704,CDM,352,RC,72130,HCPCS,Outpatient,,,3545,2836,,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1992.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,3190.5,90,,,percent of total billed charges,90% of total billed charges,1240.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2435.42,68.7,,,percent of total billed charges,68.7% of total billed charges,2836,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,2056.1,58,,,percent of total billed charges,58% of total billed charges,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,3190.5,
CT of abdomen with and without dye,4274170,CDM,352,RC,74170,HCPCS,Outpatient,,,3545,2836,,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2002.93,56.5,,,percent of total billed charges,56.5 percent of total billed charges,1992.29,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,3190.5,90,,,percent of total billed charges,90% of total billed charges,1240.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2435.42,68.7,,,percent of total billed charges,68.7% of total billed charges,2836,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,2056.1,58,,,percent of total billed charges,58% of total billed charges,722.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,3013.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,3190.5,
SIGMOIDOSCOPY FLEX W BIOP,1703004,CDM,750,RC,,,Outpatient,,,3575,2860,,3038.75,85,,,percent of total billed charges,85% of total billed charges,893.75,100,,,fee schedule,Pays 100% Medicare OPPS,893.75,100,,,fee schedule,Pays 100% Medicare OPPS,893.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,728.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,3217.5,90,,,percent of total billed charges,90% of total billed charges,1251.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2456.03,68.7,,,percent of total billed charges,68.7% of total billed charges,2860,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,3217.5,90,,,fee schedule,Pays 90% Medicare OPPS,2073.5,58,,,percent of total billed charges,58% of total billed charges,728.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3038.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,728.23,3217.5,
EGD WITH PEG PLACEMENT,1703013,CDM,750,RC,43246,HCPCS,Outpatient,,,3575,2860,,3038.75,85,,,percent of total billed charges,85% of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1991.42,130,,,fee schedule,Pays 130% Medicare OPPS,728.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,1488.23,102,,,fee schedule,Pays 102% Medicare OPPS,3217.5,90,,,percent of total billed charges,90% of total billed charges,1251.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2456.03,68.7,,,percent of total billed charges,68.7% of total billed charges,2860,80,,,percent of total billed charges,80 percent of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1313.14,90,,,fee schedule,Pays 90% Medicare OPPS,2073.5,58,,,percent of total billed charges,58% of total billed charges,728.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1531.86,100,,,fee schedule,Pays 100% Medicare OPPS,1991.42,130,,,fee schedule,Pays 130% Medicare OPPS,3038.75,85,,,percent of total billed charges,85% of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,728.23,3217.5,
SIGMOIDOSCOPY FLEX W POLY,1703021,CDM,750,RC,45338,HCPCS,Outpatient,,,3575,2860,,3038.75,85,,,percent of total billed charges,85% of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,1238.25,130,,,fee schedule,Pays 130% Medicare OPPS,728.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,950.15,102,,,fee schedule,Pays 102% Medicare OPPS,3217.5,90,,,percent of total billed charges,90% of total billed charges,1251.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2456.03,68.7,,,percent of total billed charges,68.7% of total billed charges,2860,80,,,percent of total billed charges,80 percent of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,838.37,90,,,fee schedule,Pays 90% Medicare OPPS,2073.5,58,,,percent of total billed charges,58% of total billed charges,728.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,952.5,100,,,fee schedule,Pays 100% Medicare OPPS,1238.25,130,,,fee schedule,Pays 130% Medicare OPPS,3038.75,85,,,percent of total billed charges,85% of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,728.23,3217.5,
EGD W/DILITATION GDE WIRE,1703024,CDM,750,RC,43248,HCPCS,Outpatient,,,3575,2860,,3038.75,85,,,percent of total billed charges,85% of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,943.93,130,,,fee schedule,Pays 130% Medicare OPPS,728.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,741.4,102,,,fee schedule,Pays 102% Medicare OPPS,3217.5,90,,,percent of total billed charges,90% of total billed charges,1251.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2456.03,68.7,,,percent of total billed charges,68.7% of total billed charges,2860,80,,,percent of total billed charges,80 percent of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,654.17,90,,,fee schedule,Pays 90% Medicare OPPS,2073.5,58,,,percent of total billed charges,58% of total billed charges,728.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,726.1,100,,,fee schedule,Pays 100% Medicare OPPS,943.93,130,,,fee schedule,Pays 130% Medicare OPPS,3038.75,85,,,percent of total billed charges,85% of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,654.17,3217.5,
EGD W/ABLATION TUMOR/POLYP,1743250,CDM,750,RC,,,Outpatient,,,3575,2860,,3038.75,85,,,percent of total billed charges,85% of total billed charges,893.75,100,,,fee schedule,Pays 100% Medicare OPPS,893.75,100,,,fee schedule,Pays 100% Medicare OPPS,893.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,728.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,3217.5,90,,,percent of total billed charges,90% of total billed charges,1251.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2456.03,68.7,,,percent of total billed charges,68.7% of total billed charges,2860,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,3217.5,90,,,fee schedule,Pays 90% Medicare OPPS,2073.5,58,,,percent of total billed charges,58% of total billed charges,728.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3038.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,728.23,3217.5,
SIGMOIDOSCOPY AND BIOPSY,1745331,CDM,750,RC,45331,HCPCS,Outpatient,,,3575,2860,,3038.75,85,,,percent of total billed charges,85% of total billed charges,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,950.25,130,,,fee schedule,Pays 130% Medicare ,728.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,727.13,102,,,fee schedule,Pays 102% Medicare OPPS,3217.5,90,,,percent of total billed charges,90% of total billed charges,1251.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2456.03,68.7,,,percent of total billed charges,68.7% of total billed charges,2860,80,,,percent of total billed charges,80 percent of total billed charges,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,641.59,90,,,fee schedule,Pays 90% Medicare OPPS,2073.5,58,,,percent of total billed charges,58% of total billed charges,728.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,730.96,100,,,fee schedule,Pays 100% Medicare OPPS,950.25,130,,,fee schedule,Pays 130% Medicare ,3038.75,85,,,percent of total billed charges,85% of total billed charges,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,641.59,3217.5,
IMPLANT BREAST SMTH RND HIGH PROF XTRA,1570990,CDM,278,RC,,,Both,,,3640,2912,,3094,85,,,percent of total billed charges,85% of total billed charges,910,100,,,fee schedule,Pays 100% Medicare ,910,100,,,fee schedule,Pays 100% Medicare ,910,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,741.47,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1899.02,52.17,,,case rate,100% of BCBS case rate,1899.02,52.17,,,case rate,100% of BCBS case rate,1899.02,52.17,,,case rate,100% of BCBS case rate,1899.02,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,3276,90,,,percent of total billed charges,90% of total billed charges,1274,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2500.68,68.7,,,percent of total billed charges,68.7% of total billed charges,2912,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,3276,90,,,fee schedule,Pays 90% Medicare ,2111.2,58,,,percent of total billed charges,58% of total billed charges,741.47,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3094,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,741.47,3276,
IMPLANT BREAST SMTH RND HIGH PROF XTRA,1570991,CDM,278,RC,,,Both,,,3640,2912,,3094,85,,,percent of total billed charges,85% of total billed charges,910,100,,,fee schedule,Pays 100% Medicare ,910,100,,,fee schedule,Pays 100% Medicare ,910,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,741.47,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1899.02,52.17,,,case rate,100% of BCBS case rate,1899.02,52.17,,,case rate,100% of BCBS case rate,1899.02,52.17,,,case rate,100% of BCBS case rate,1899.02,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,3276,90,,,percent of total billed charges,90% of total billed charges,1274,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2500.68,68.7,,,percent of total billed charges,68.7% of total billed charges,2912,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,3276,90,,,fee schedule,Pays 90% Medicare ,2111.2,58,,,percent of total billed charges,58% of total billed charges,741.47,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3094,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,741.47,3276,
IMPLANT BREAST SMTH RND HIGH PROF XTRA,1570992,CDM,278,RC,,,Both,,,3640,2912,,3094,85,,,percent of total billed charges,85% of total billed charges,910,100,,,fee schedule,Pays 100% Medicare ,910,100,,,fee schedule,Pays 100% Medicare ,910,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,741.47,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1899.02,52.17,,,case rate,100% of BCBS case rate,1899.02,52.17,,,case rate,100% of BCBS case rate,1899.02,52.17,,,case rate,100% of BCBS case rate,1899.02,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,3276,90,,,percent of total billed charges,90% of total billed charges,1274,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2500.68,68.7,,,percent of total billed charges,68.7% of total billed charges,2912,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,3276,90,,,fee schedule,Pays 90% Medicare ,2111.2,58,,,percent of total billed charges,58% of total billed charges,741.47,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3094,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,741.47,3276,
IMPLANT BREAST SMTH RND HIGH PROF XTRA,1570993,CDM,278,RC,,,Both,,,3640,2912,,3094,85,,,percent of total billed charges,85% of total billed charges,910,100,,,fee schedule,Pays 100% Medicare ,910,100,,,fee schedule,Pays 100% Medicare ,910,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,741.47,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1899.02,52.17,,,case rate,100% of BCBS case rate,1899.02,52.17,,,case rate,100% of BCBS case rate,1899.02,52.17,,,case rate,100% of BCBS case rate,1899.02,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,3276,90,,,percent of total billed charges,90% of total billed charges,1274,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2500.68,68.7,,,percent of total billed charges,68.7% of total billed charges,2912,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,3276,90,,,fee schedule,Pays 90% Medicare ,2111.2,58,,,percent of total billed charges,58% of total billed charges,741.47,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3094,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,741.47,3276,
IMPLANT BREAST SMTH RND HIGH PROF XTRA,1570994,CDM,278,RC,,,Both,,,3640,2912,,3094,85,,,percent of total billed charges,85% of total billed charges,910,100,,,fee schedule,Pays 100% Medicare ,910,100,,,fee schedule,Pays 100% Medicare ,910,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,741.47,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1899.02,52.17,,,case rate,100% of BCBS case rate,1899.02,52.17,,,case rate,100% of BCBS case rate,1899.02,52.17,,,case rate,100% of BCBS case rate,1899.02,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,3276,90,,,percent of total billed charges,90% of total billed charges,1274,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2500.68,68.7,,,percent of total billed charges,68.7% of total billed charges,2912,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,3276,90,,,fee schedule,Pays 90% Medicare ,2111.2,58,,,percent of total billed charges,58% of total billed charges,741.47,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3094,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,741.47,3276,
IMPLANT BREAST SMTH RND HIGH PROF XTRA,1570995,CDM,278,RC,,,Both,,,3640,2912,,3094,85,,,percent of total billed charges,85% of total billed charges,910,100,,,fee schedule,Pays 100% Medicare ,910,100,,,fee schedule,Pays 100% Medicare ,910,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,741.47,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1899.02,52.17,,,case rate,100% of BCBS case rate,1899.02,52.17,,,case rate,100% of BCBS case rate,1899.02,52.17,,,case rate,100% of BCBS case rate,1899.02,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,3276,90,,,percent of total billed charges,90% of total billed charges,1274,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2500.68,68.7,,,percent of total billed charges,68.7% of total billed charges,2912,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,3276,90,,,fee schedule,Pays 90% Medicare ,2111.2,58,,,percent of total billed charges,58% of total billed charges,741.47,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3094,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,741.47,3276,
CTA LOWER EXTREMITY W/WO,4273706,CDM,352,RC,73706,HCPCS,Outpatient,,,3650,2920,,3102.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,743.51,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2062.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2062.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2062.25,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2051.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,3285,90,,,percent of total billed charges,90% of total billed charges,1277.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2507.55,68.7,,,percent of total billed charges,68.7% of total billed charges,2920,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,2117,58,,,percent of total billed charges,58% of total billed charges,743.51,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,3102.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,3285,
SINUS BALLOON CATHETER 7MM ULTIRRA,1570759,CDM,272,RC,,,Outpatient,,,3685,2948,,3132.25,85,,,percent of total billed charges,85% of total billed charges,921.25,100,,,fee schedule,Pays 100% Medicare OPPS,921.25,100,,,fee schedule,Pays 100% Medicare OPPS,921.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,750.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,3316.5,90,,,percent of total billed charges,90% of total billed charges,1289.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2531.6,68.7,,,percent of total billed charges,68.7% of total billed charges,2948,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,3316.5,90,,,fee schedule,Pays 90% Medicare OPPS,2137.3,58,,,percent of total billed charges,58% of total billed charges,750.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3132.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,750.63,3316.5,
SINUS BALLOON CATHETER 5MM ULTIRRA,1570760,CDM,272,RC,,,Outpatient,,,3685,2948,,3132.25,85,,,percent of total billed charges,85% of total billed charges,921.25,100,,,fee schedule,Pays 100% Medicare OPPS,921.25,100,,,fee schedule,Pays 100% Medicare OPPS,921.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,750.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,3316.5,90,,,percent of total billed charges,90% of total billed charges,1289.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2531.6,68.7,,,percent of total billed charges,68.7% of total billed charges,2948,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,3316.5,90,,,fee schedule,Pays 90% Medicare OPPS,2137.3,58,,,percent of total billed charges,58% of total billed charges,750.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3132.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,750.63,3316.5,
EXCISION BEN LESION 2.1-3.0CM,1711403,CDM,360,RC,11403,HCPCS,Outpatient,,,3725,2980,,3166.25,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,742.06,130,,,fee schedule,Pays 130% Medicare OPPS,758.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,570.17,102,,,fee schedule,Pays 102% Medicare OPPS,3352.5,90,,,percent of total billed charges,90% of total billed charges,1303.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2559.08,68.7,,,percent of total billed charges,68.7% of total billed charges,2980,80,,,percent of total billed charges,80 percent of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,503.1,90,,,fee schedule,Pays 90% Medicare OPPS,2160.5,58,,,percent of total billed charges,58% of total billed charges,758.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,570.82,100,,,fee schedule,Pays 100% Medicare OPPS,742.06,130,,,fee schedule,Pays 130% Medicare OPPS,3166.25,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,503.1,3352.5,
REMOVAL OF FOREIGN BODY PELVIS OR HIP,2027086,CDM,450,RC,27086,HCPCS,Outpatient,,,3725,2980,,3166.25,85,,,percent of total billed charges,85% of total billed charges,2129.94,100,,,fee schedule,Pays 100% Medicare OPPS,2129.94,100,,,fee schedule,Pays 100% Medicare OPPS,2129.94,100,,,fee schedule,Pays 100% Medicare OPPS,2953.82,130,,,fee schedule,Pays 130% Medicare OPPS,758.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2172.54,102,,,fee schedule,Pays 102% Medicare OPPS,3352.5,90,,,percent of total billed charges,90% of total billed charges,1303.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2559.08,68.7,,,percent of total billed charges,68.7% of total billed charges,2980,80,,,percent of total billed charges,80 percent of total billed charges,2129.94,100,,,fee schedule,Pays 100% Medicare OPPS,1916.94,90,,,fee schedule,Pays 90% Medicare OPPS,2160.5,58,,,percent of total billed charges,58% of total billed charges,758.78,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2272.17,100,,,fee schedule,Pays 100% Medicare OPPS,2953.82,130,,,fee schedule,Pays 130% Medicare OPPS,3166.25,85,,,percent of total billed charges,85% of total billed charges,2129.94,100,,,fee schedule,Pays 100% Medicare OPPS,758.78,3352.5,
REMOVAL OF HEMORRHOID CLOT,1546320,CDM,360,RC,46320,HCPCS,Outpatient,,,3750,3000,,3187.5,85,,,percent of total billed charges,85% of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,1238.25,130,,,fee schedule,Pays 130% Medicare OPPS,763.88,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,950.15,102,,,fee schedule,Pays 102% Medicare OPPS,3375,90,,,percent of total billed charges,90% of total billed charges,1312.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2576.25,68.7,,,percent of total billed charges,68.7% of total billed charges,3000,80,,,percent of total billed charges,80 percent of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,838.37,90,,,fee schedule,Pays 90% Medicare OPPS,2175,58,,,percent of total billed charges,58% of total billed charges,763.88,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,952.5,100,,,fee schedule,Pays 100% Medicare OPPS,1238.25,130,,,fee schedule,Pays 130% Medicare OPPS,3187.5,85,,,percent of total billed charges,85% of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,763.88,3375,
REMOVAL OF TUNNELED CV CATH,1536590,CDM,360,RC,36590,HCPCS,Outpatient,,,3775,3020,,3208.75,85,,,percent of total billed charges,85% of total billed charges,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,1701.28,130,,,fee schedule,Pays 130% Medicare OPPS,768.97,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,1288.48,102,,,fee schedule,Pays 102% Medicare OPPS,3397.5,90,,,percent of total billed charges,90% of total billed charges,1321.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2593.43,68.7,,,percent of total billed charges,68.7% of total billed charges,3020,80,,,percent of total billed charges,80 percent of total billed charges,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,1136.89,90,,,fee schedule,Pays 90% Medicare OPPS,2189.5,58,,,percent of total billed charges,58% of total billed charges,768.97,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1308.68,100,,,fee schedule,Pays 100% Medicare OPPS,1701.28,130,,,fee schedule,Pays 130% Medicare OPPS,3208.75,85,,,percent of total billed charges,85% of total billed charges,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,768.97,3397.5,
CLTX RDL FX/EPIIP,2025605,CDM,450,RC,25605,HCPCS,Outpatient,,,3795,3036,,3225.75,85,,,percent of total billed charges,85% of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1640.3,130,,,fee schedule,Pays 130% Medicare OPPS,773.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,1276.23,102,,,fee schedule,Pays 102% Medicare OPPS,3415.5,90,,,percent of total billed charges,90% of total billed charges,1328.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2607.17,68.7,,,percent of total billed charges,68.7% of total billed charges,3036,80,,,percent of total billed charges,80 percent of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1126.08,90,,,fee schedule,Pays 90% Medicare OPPS,2201.1,58,,,percent of total billed charges,58% of total billed charges,773.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1261.77,100,,,fee schedule,Pays 100% Medicare OPPS,1640.3,130,,,fee schedule,Pays 130% Medicare OPPS,3225.75,85,,,percent of total billed charges,85% of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,773.04,3415.5,
CL TX FEMUR FX OR EPIPHYS SEP,2027510,CDM,450,RC,27510,HCPCS,Outpatient,,,3795,3036,,3225.75,85,,,percent of total billed charges,85% of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1640.3,130,,,fee schedule,Pays 130% Medicare OPPS,773.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,1276.23,102,,,fee schedule,Pays 102% Medicare OPPS,3415.5,90,,,percent of total billed charges,90% of total billed charges,1328.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2607.17,68.7,,,percent of total billed charges,68.7% of total billed charges,3036,80,,,percent of total billed charges,80 percent of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1126.08,90,,,fee schedule,Pays 90% Medicare OPPS,2201.1,58,,,percent of total billed charges,58% of total billed charges,773.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1261.77,100,,,fee schedule,Pays 100% Medicare OPPS,1640.3,130,,,fee schedule,Pays 130% Medicare OPPS,3225.75,85,,,percent of total billed charges,85% of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,773.04,3415.5,
CTA PELVIS W/WO,4272191,CDM,350,RC,72191,HCPCS,Outpatient,,,3845,3076,,3268.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,783.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2172.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2172.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2172.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2160.89,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,3460.5,90,,,percent of total billed charges,90% of total billed charges,1345.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2641.52,68.7,,,percent of total billed charges,68.7% of total billed charges,3076,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,2230.1,58,,,percent of total billed charges,58% of total billed charges,783.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,3268.25,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,3460.5,
SINUS BALLOON CATHETER 3.5MM ULTIRRA,1570758,CDM,272,RC,,,Outpatient,,,3860,3088,,3281,85,,,percent of total billed charges,85% of total billed charges,965,100,,,fee schedule,Pays 100% Medicare OPPS,965,100,,,fee schedule,Pays 100% Medicare OPPS,965,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,786.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,3474,90,,,percent of total billed charges,90% of total billed charges,1351,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2651.82,68.7,,,percent of total billed charges,68.7% of total billed charges,3088,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,3474,90,,,fee schedule,Pays 90% Medicare OPPS,2238.8,58,,,percent of total billed charges,58% of total billed charges,786.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3281,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,786.28,3474,
EGD WITH DILITATION,1703019,CDM,750,RC,,,Outpatient,,,3910,3128,,3323.5,85,,,percent of total billed charges,85% of total billed charges,977.5,100,,,fee schedule,Pays 100% Medicare OPPS,977.5,100,,,fee schedule,Pays 100% Medicare OPPS,977.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,796.47,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,3519,90,,,percent of total billed charges,90% of total billed charges,1368.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2686.17,68.7,,,percent of total billed charges,68.7% of total billed charges,3128,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,3519,90,,,fee schedule,Pays 90% Medicare OPPS,2267.8,58,,,percent of total billed charges,58% of total billed charges,796.47,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3323.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,796.47,3519,
ESOPHAGAL DILITATION,1705035,CDM,750,RC,43248,HCPCS,Outpatient,,,3910,3128,,3323.5,85,,,percent of total billed charges,85% of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,943.93,130,,,fee schedule,Pays 130% Medicare OPPS,796.47,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,741.4,102,,,fee schedule,Pays 102% Medicare OPPS,3519,90,,,percent of total billed charges,90% of total billed charges,1368.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2686.17,68.7,,,percent of total billed charges,68.7% of total billed charges,3128,80,,,percent of total billed charges,80 percent of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,654.17,90,,,fee schedule,Pays 90% Medicare OPPS,2267.8,58,,,percent of total billed charges,58% of total billed charges,796.47,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,726.1,100,,,fee schedule,Pays 100% Medicare OPPS,943.93,130,,,fee schedule,Pays 130% Medicare OPPS,3323.5,85,,,percent of total billed charges,85% of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,654.17,3519,
CTA ABDOMEN W/WO,4274175,CDM,352,RC,74175,HCPCS,Outpatient,,,3915,3132,,3327.75,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,797.49,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2211.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2211.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2211.98,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2200.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,3523.5,90,,,percent of total billed charges,90% of total billed charges,1370.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2689.61,68.7,,,percent of total billed charges,68.7% of total billed charges,3132,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,2270.7,58,,,percent of total billed charges,58% of total billed charges,797.49,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,3327.75,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,3523.5,
UPPER GI SCOPE W SUBMUC INJ,1743236,CDM,750,RC,43236,HCPCS,Outpatient,,,3940,3152,,3349,85,,,percent of total billed charges,85% of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,943.93,130,,,fee schedule,Pays 130% Medicare OPPS,802.58,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,741.4,102,,,fee schedule,Pays 102% Medicare OPPS,3546,90,,,percent of total billed charges,90% of total billed charges,1379,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2706.78,68.7,,,percent of total billed charges,68.7% of total billed charges,3152,80,,,percent of total billed charges,80 percent of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,654.17,90,,,fee schedule,Pays 90% Medicare OPPS,2285.2,58,,,percent of total billed charges,58% of total billed charges,802.58,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,726.1,100,,,fee schedule,Pays 100% Medicare OPPS,943.93,130,,,fee schedule,Pays 130% Medicare OPPS,3349,85,,,percent of total billed charges,85% of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,654.17,3546,
CL TX WB DSTL TIB FX W MANIP,2027825,CDM,450,RC,27825,HCPCS,Outpatient,,,3940,3152,,3349,85,,,percent of total billed charges,85% of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1640.3,130,,,fee schedule,Pays 130% Medicare OPPS,802.58,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,1276.23,102,,,fee schedule,Pays 102% Medicare OPPS,3546,90,,,percent of total billed charges,90% of total billed charges,1379,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2706.78,68.7,,,percent of total billed charges,68.7% of total billed charges,3152,80,,,percent of total billed charges,80 percent of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1126.08,90,,,fee schedule,Pays 90% Medicare OPPS,2285.2,58,,,percent of total billed charges,58% of total billed charges,802.58,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1261.77,100,,,fee schedule,Pays 100% Medicare OPPS,1640.3,130,,,fee schedule,Pays 130% Medicare OPPS,3349,85,,,percent of total billed charges,85% of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,802.58,3546,
Diagnostic Radiology (Diagnostic Imaging) Procedures of the Chest,4271275,CDM,350,RC,71275,HCPCS,Outpatient,,,3960,3168,,3366,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,806.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2237.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2237.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2237.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2225.52,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,3564,90,,,percent of total billed charges,90% of total billed charges,1386,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2720.52,68.7,,,percent of total billed charges,68.7% of total billed charges,3168,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,2296.8,58,,,percent of total billed charges,58% of total billed charges,806.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,3366,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,3564,
BIOPSY BREAST W LOCALIZATION DEVICE,4019083,CDM,360,RC,19083,HCPCS,Outpatient,,,3975,3180,,3378.75,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,809.71,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,1289.21,102,,,fee schedule,Pays 102% Medicare OPPS,3577.5,90,,,percent of total billed charges,90% of total billed charges,1391.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2730.83,68.7,,,percent of total billed charges,68.7% of total billed charges,3180,80,,,percent of total billed charges,80 percent of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1137.55,90,,,fee schedule,Pays 90% Medicare OPPS,2305.5,58,,,percent of total billed charges,58% of total billed charges,809.71,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1318.97,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,3378.75,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,809.71,3577.5,
CTA HEAD W/WO,4270496,CDM,350,RC,70496,HCPCS,Outpatient,,,3990,3192,,3391.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,812.76,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2254.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2254.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2254.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2242.38,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,3591,90,,,percent of total billed charges,90% of total billed charges,1396.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2741.13,68.7,,,percent of total billed charges,68.7% of total billed charges,3192,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,2314.2,58,,,percent of total billed charges,58% of total billed charges,812.76,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare OPPS,3391.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,3591,
OR ACUITY LEVEL 1-B 1ST HOUR,1501149,CDM,360,RC,,,Outpatient,,,4000,3200,,3400,85,,,percent of total billed charges,85% of total billed charges,1000,100,,,fee schedule,Pays 100% Medicare OPPS,1000,100,,,fee schedule,Pays 100% Medicare OPPS,1000,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,814.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,3600,90,,,percent of total billed charges,90% of total billed charges,1400,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2748,68.7,,,percent of total billed charges,68.7% of total billed charges,3200,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,3600,90,,,fee schedule,Pays 90% Medicare OPPS,2320,58,,,percent of total billed charges,58% of total billed charges,814.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3400,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,814.8,3600,
POLYSOMNOGRAPHY YOUNGER 6YRS,1595782,CDM,920,RC,95782,HCPCS,Outpatient,,,4000,3200,,3400,85,,,percent of total billed charges,85% of total billed charges,826.46,100,,,fee schedule,Pays 100% Medicare OPPS,826.46,100,,,fee schedule,Pays 100% Medicare OPPS,826.46,100,,,fee schedule,Pays 100% Medicare OPPS,1068.41,130,,,fee schedule,Pays 130% Medicare OPPS,814.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,842.98,102,,,fee schedule,Pays 102% Medicare OPPS,3600,90,,,percent of total billed charges,90% of total billed charges,1400,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2748,68.7,,,percent of total billed charges,68.7% of total billed charges,3200,80,,,percent of total billed charges,80 percent of total billed charges,826.46,100,,,fee schedule,Pays 100% Medicare OPPS,743.8,90,,,fee schedule,Pays 90% Medicare OPPS,2320,58,,,percent of total billed charges,58% of total billed charges,814.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,821.86,100,,,fee schedule,Pays 100% Medicare OPPS,1068.41,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,826.46,100,,,fee schedule,Pays 100% Medicare OPPS,743.8,3600,
Sleep monitoring of patient (6 years or older) in sleep lab,1595810,CDM,920,RC,95810,HCPCS,Outpatient,,,4000,3200,,3400,85,,,percent of total billed charges,85% of total billed charges,826.46,100,,,fee schedule,Pays 100% Medicare OPPS,826.46,100,,,fee schedule,Pays 100% Medicare OPPS,826.46,100,,,fee schedule,Pays 100% Medicare OPPS,1068.41,130,,,fee schedule,Pays 130% Medicare ,814.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,842.98,102,,,fee schedule,Pays 102% Medicare OPPS,3600,90,,,percent of total billed charges,90% of total billed charges,1400,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2748,68.7,,,percent of total billed charges,68.7% of total billed charges,3200,80,,,percent of total billed charges,80 percent of total billed charges,826.46,100,,,fee schedule,Pays 100% Medicare OPPS,743.8,90,,,fee schedule,Pays 90% Medicare OPPS,2320,58,,,percent of total billed charges,58% of total billed charges,814.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,821.86,100,,,fee schedule,Pays 100% Medicare OPPS,1068.41,130,,,fee schedule,Pays 130% Medicare ,,,,,other,Not reimbursed per contract,826.46,100,,,fee schedule,Pays 100% Medicare OPPS,743.8,3600,
Sleep monitoring of patient (6 years or older) in sleep lab using CPAP,1595811,CDM,920,RC,95811,HCPCS,Outpatient,,,4000,3200,,3400,85,,,percent of total billed charges,85% of total billed charges,826.46,100,,,fee schedule,Pays 100% Medicare OPPS,826.46,100,,,fee schedule,Pays 100% Medicare OPPS,826.46,100,,,fee schedule,Pays 100% Medicare OPPS,1068.41,130,,,fee schedule,Pays 130% Medicare OPPS,814.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,842.98,102,,,fee schedule,Pays 102% Medicare OPPS,3600,90,,,percent of total billed charges,90% of total billed charges,1400,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2748,68.7,,,percent of total billed charges,68.7% of total billed charges,3200,80,,,percent of total billed charges,80 percent of total billed charges,826.46,100,,,fee schedule,Pays 100% Medicare OPPS,743.8,90,,,fee schedule,Pays 90% Medicare OPPS,2320,58,,,percent of total billed charges,58% of total billed charges,814.8,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,821.86,100,,,fee schedule,Pays 100% Medicare OPPS,1068.41,130,,,fee schedule,Pays 130% Medicare OPPS,,,,,other,Not reimbursed per contract,826.46,100,,,fee schedule,Pays 100% Medicare OPPS,743.8,3600,
DIGIBIND (DIG IMMUNE FAB) INJ 38MG,2602235,CDM,636,RC,J1162,HCPCS,Both,,,4070,3256,,3459.5,85,,,percent of total billed charges,85% of total billed charges,4294.08,100,,,fee schedule,Pays 100% Medicare ,4294.08,100,,,fee schedule,Pays 100% Medicare ,4294.08,100,,,fee schedule,Pays 100% Medicare ,5971.64,130,,,fee schedule,Pays 130% Medicare OPPS,829.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2123.36,52.17,,,case rate,100% of BCBS case rate,2123.36,52.17,,,case rate,100% of BCBS case rate,2123.36,52.17,,,case rate,100% of BCBS case rate,2123.36,52.17,,,case rate,100% of BCBS case rate,4379.96,102,,,fee schedule,Pays 102% Medicare ,3663,90,,,percent of total billed charges,90% of total billed charges,1424.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2796.09,68.7,,,percent of total billed charges,68.7% of total billed charges,3256,80,,,percent of total billed charges,80 percent of total billed charges,4294.08,100,,,fee schedule,Pays 100% Medicare ,3864.67,90,,,fee schedule,Pays 90% Medicare ,2360.6,58,,,percent of total billed charges,58% of total billed charges,829.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4593.57,100,,,fee schedule,Pays 100% Medicare ,5971.64,130,,,fee schedule,Pays 130% Medicare OPPS,3459.5,85,,,percent of total billed charges,85% of total billed charges,4294.08,100,,,fee schedule,Pays 100% Medicare ,829.06,5971.64,
CTA NECK W/WO,4270498,CDM,351,RC,70498,HCPCS,Outpatient,,,4070,3256,,3459.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare ,829.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2299.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2299.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2299.55,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2287.34,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.66,102,,,fee schedule,Pays 102% Medicare OPPS,3663,90,,,percent of total billed charges,90% of total billed charges,1424.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2796.09,68.7,,,percent of total billed charges,68.7% of total billed charges,3256,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,2360.6,58,,,percent of total billed charges,58% of total billed charges,829.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.2,130,,,fee schedule,Pays 130% Medicare ,3459.5,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,3663,
"Emergency department visit, problem of high severity",2000000,CDM,450,RC,99284,HCPCS,Outpatient,,,4100,3280,,3485,85,,,percent of total billed charges,85% of total billed charges,326.77,100,,,fee schedule,Pays 100% Medicare OPPS,326.77,100,,,fee schedule,Pays 100% Medicare OPPS,326.77,100,,,fee schedule,Pays 100% Medicare OPPS,436.35,130,,,fee schedule,Pays 130% Medicare ,835.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4100,100,,,percent of total billed charges,671 dollar flat fee for ER,4100,100,,,percent of total billed charges,671 dollar flat fee for ER,4100,100,,,percent of total billed charges,671 dollar flat fee for ER,4100,100,,,percent of total billed charges,671 dollar flat fee for ER,333.31,102,,,fee schedule,Pays 102% Medicare OPPS,3690,90,,,percent of total billed charges,90% of total billed charges,1435,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2816.7,68.7,,,percent of total billed charges,68.7% of total billed charges,3280,80,,,percent of total billed charges,80 percent of total billed charges,326.77,100,,,fee schedule,Pays 100% Medicare OPPS,294.08,90,,,fee schedule,Pays 90% Medicare OPPS,2378,58,,,percent of total billed charges,58% of total billed charges,835.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,335.65,100,,,fee schedule,Pays 100% Medicare OPPS,436.35,130,,,fee schedule,Pays 130% Medicare ,3485,85,,,percent of total billed charges,85% of total billed charges,326.77,100,,,fee schedule,Pays 100% Medicare OPPS,294.08,4100,
HERNIA ECHO 2 POSITIONING SYSTEM 5990015,1570059,CDM,278,RC,C1781,HCPCS,Both,,,4120,3296,,3502,85,,,percent of total billed charges,85% of total billed charges,1030,100,,,fee schedule,Pays 100% Medicare ,1030,100,,,fee schedule,Pays 100% Medicare ,1030,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,839.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2149.45,52.17,,,case rate,100% of BCBS case rate,2149.45,52.17,,,case rate,100% of BCBS case rate,2149.45,52.17,,,case rate,100% of BCBS case rate,2149.45,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,3708,90,,,percent of total billed charges,90% of total billed charges,1442,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2830.44,68.7,,,percent of total billed charges,68.7% of total billed charges,3296,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,3708,90,,,fee schedule,Pays 90% Medicare ,2389.6,58,,,percent of total billed charges,58% of total billed charges,839.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3502,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,839.24,3708,
AREDIA (PAMIDRONATE) INJ : 90MG,2605020,CDM,636,RC,J2430,HCPCS,Both,,,4130,3304,,3510.5,85,,,percent of total billed charges,85% of total billed charges,1032.5,100,,,fee schedule,Pays 100% Medicare ,1032.5,100,,,fee schedule,Pays 100% Medicare ,1032.5,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,13.22,120.37,,,fee schedule,120.37% of custom fee schedule,2154.66,52.17,,,case rate,100% of BCBS case rate,2154.66,52.17,,,case rate,100% of BCBS case rate,2154.66,52.17,,,case rate,100% of BCBS case rate,2154.66,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,3717,90,,,percent of total billed charges,90% of total billed charges,13.74,125.18,,,fee schedule,125.18% of custom fee schedule,2837.31,68.7,,,percent of total billed charges,68.7% of total billed charges,3304,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,3717,90,,,fee schedule,Pays 90% Medicare ,2395.4,58,,,percent of total billed charges,58% of total billed charges,13.22,120.37,,,fee schedule,120.37% of custom fee schedule,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3510.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,13.22,3717,
REPAIR BLOOD VESSEL DIRECT LOW EXT,2035226,CDM,450,RC,35226,HCPCS,Outpatient,,,4140,3312,,3519,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,559,100,,,fee schedule,Pays 100% Medicare OPPS,742.06,130,,,fee schedule,Pays 130% Medicare OPPS,843.32,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,570.17,102,,,fee schedule,Pays 102% Medicare OPPS,3726,90,,,percent of total billed charges,90% of total billed charges,1449,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2844.18,68.7,,,percent of total billed charges,68.7% of total billed charges,3312,80,,,percent of total billed charges,80 percent of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,503.1,90,,,fee schedule,Pays 90% Medicare OPPS,2401.2,58,,,percent of total billed charges,58% of total billed charges,843.32,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,570.82,100,,,fee schedule,Pays 100% Medicare OPPS,742.06,130,,,fee schedule,Pays 130% Medicare OPPS,3519,85,,,percent of total billed charges,85% of total billed charges,559,100,,,fee schedule,Pays 100% Medicare OPPS,503.1,3726,
SIGMODOSCOPY W/ABLATION,1745346,CDM,360,RC,45346,HCPCS,Outpatient,,,4200,3360,,3570,85,,,percent of total billed charges,85% of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,1238.25,130,,,fee schedule,Pays 130% Medicare OPPS,855.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,950.15,102,,,fee schedule,Pays 102% Medicare OPPS,3780,90,,,percent of total billed charges,90% of total billed charges,1470,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2885.4,68.7,,,percent of total billed charges,68.7% of total billed charges,3360,80,,,percent of total billed charges,80 percent of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,838.37,90,,,fee schedule,Pays 90% Medicare OPPS,2436,58,,,percent of total billed charges,58% of total billed charges,855.54,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,952.5,100,,,fee schedule,Pays 100% Medicare OPPS,1238.25,130,,,fee schedule,Pays 130% Medicare OPPS,3570,85,,,percent of total billed charges,85% of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,838.37,3780,
COLONOSCOPY WITH ABLATION,1703027,CDM,750,RC,,,Outpatient,,,4225,3380,,3591.25,85,,,percent of total billed charges,85% of total billed charges,1056.25,100,,,fee schedule,Pays 100% Medicare OPPS,1056.25,100,,,fee schedule,Pays 100% Medicare OPPS,1056.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,860.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,3802.5,90,,,percent of total billed charges,90% of total billed charges,1478.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2902.58,68.7,,,percent of total billed charges,68.7% of total billed charges,3380,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,3802.5,90,,,fee schedule,Pays 90% Medicare OPPS,2450.5,58,,,percent of total billed charges,58% of total billed charges,860.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3591.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,860.63,3802.5,
SIGMOIDOSCOPY TUMOR/POLYP,1703030,CDM,750,RC,,,Outpatient,,,4225,3380,,3591.25,85,,,percent of total billed charges,85% of total billed charges,1056.25,100,,,fee schedule,Pays 100% Medicare OPPS,1056.25,100,,,fee schedule,Pays 100% Medicare OPPS,1056.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,860.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,3802.5,90,,,percent of total billed charges,90% of total billed charges,1478.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2902.58,68.7,,,percent of total billed charges,68.7% of total billed charges,3380,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,3802.5,90,,,fee schedule,Pays 90% Medicare OPPS,2450.5,58,,,percent of total billed charges,58% of total billed charges,860.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3591.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,860.63,3802.5,
GRAFTJACKET MATRIX 2 x 4,1570056,CDM,278,RC,Q4107,HCPCS,Both,,,4240,3392,,3604,85,,,percent of total billed charges,85% of total billed charges,1060,100,,,fee schedule,Pays 100% Medicare ,1060,100,,,fee schedule,Pays 100% Medicare ,1060,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,863.69,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2212.05,52.17,,,case rate,100% of BCBS case rate,2212.05,52.17,,,case rate,100% of BCBS case rate,2212.05,52.17,,,case rate,100% of BCBS case rate,2212.05,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,3816,90,,,percent of total billed charges,90% of total billed charges,1484,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2912.88,68.7,,,percent of total billed charges,68.7% of total billed charges,3392,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,3816,90,,,fee schedule,Pays 90% Medicare ,2459.2,58,,,percent of total billed charges,58% of total billed charges,863.69,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3604,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,863.69,3816,
IMPLANT HAMMERTOE KIT,1570187,CDM,278,RC,C1776,HCPCS,Both,,,4240,3392,,3604,85,,,percent of total billed charges,85% of total billed charges,1060,100,,,fee schedule,Pays 100% Medicare ,1060,100,,,fee schedule,Pays 100% Medicare ,1060,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,863.69,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2212.05,52.17,,,case rate,100% of BCBS case rate,2212.05,52.17,,,case rate,100% of BCBS case rate,2212.05,52.17,,,case rate,100% of BCBS case rate,2212.05,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,3816,90,,,percent of total billed charges,90% of total billed charges,1484,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2912.88,68.7,,,percent of total billed charges,68.7% of total billed charges,3392,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,3816,90,,,fee schedule,Pays 90% Medicare ,2459.2,58,,,percent of total billed charges,58% of total billed charges,863.69,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3604,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,863.69,3816,
IMPLANT METAL HEMIARTHROPLASTY,1570042,CDM,278,RC,L8641,HCPCS,Both,,,4345,3476,,3693.25,85,,,percent of total billed charges,85% of total billed charges,1086.25,100,,,fee schedule,Pays 100% Medicare ,1086.25,100,,,fee schedule,Pays 100% Medicare ,1086.25,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,885.08,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2266.83,52.17,,,case rate,100% of BCBS case rate,2266.83,52.17,,,case rate,100% of BCBS case rate,2266.83,52.17,,,case rate,100% of BCBS case rate,2266.83,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,3910.5,90,,,percent of total billed charges,90% of total billed charges,1520.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2985.02,68.7,,,percent of total billed charges,68.7% of total billed charges,3476,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,3910.5,90,,,fee schedule,Pays 90% Medicare ,2520.1,58,,,percent of total billed charges,58% of total billed charges,885.08,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3693.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,885.08,3910.5,
COLONOSCOPY,1703001,CDM,750,RC,,,Outpatient,,,4345,3476,,3693.25,85,,,percent of total billed charges,85% of total billed charges,1086.25,100,,,fee schedule,Pays 100% Medicare OPPS,1086.25,100,,,fee schedule,Pays 100% Medicare OPPS,1086.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,885.08,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,3910.5,90,,,percent of total billed charges,90% of total billed charges,1520.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2985.02,68.7,,,percent of total billed charges,68.7% of total billed charges,3476,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,3910.5,90,,,fee schedule,Pays 90% Medicare OPPS,2520.1,58,,,percent of total billed charges,58% of total billed charges,885.08,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3693.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,885.08,3910.5,
SIGMOIDOSCOPY W/ ABLATION OF TUMOR/POLYP,1703040,CDM,750,RC,,,Outpatient,,,4345,3476,,3693.25,85,,,percent of total billed charges,85% of total billed charges,1086.25,100,,,fee schedule,Pays 100% Medicare OPPS,1086.25,100,,,fee schedule,Pays 100% Medicare OPPS,1086.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,885.08,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,3910.5,90,,,percent of total billed charges,90% of total billed charges,1520.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2985.02,68.7,,,percent of total billed charges,68.7% of total billed charges,3476,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,3910.5,90,,,fee schedule,Pays 90% Medicare OPPS,2520.1,58,,,percent of total billed charges,58% of total billed charges,885.08,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3693.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,885.08,3910.5,
SIGMOIDOSCOPY W/ CONTROL OF BLEEDING,1703041,CDM,750,RC,,,Outpatient,,,4345,3476,,3693.25,85,,,percent of total billed charges,85% of total billed charges,1086.25,100,,,fee schedule,Pays 100% Medicare OPPS,1086.25,100,,,fee schedule,Pays 100% Medicare OPPS,1086.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,885.08,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,3910.5,90,,,percent of total billed charges,90% of total billed charges,1520.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2985.02,68.7,,,percent of total billed charges,68.7% of total billed charges,3476,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,3910.5,90,,,fee schedule,Pays 90% Medicare OPPS,2520.1,58,,,percent of total billed charges,58% of total billed charges,885.08,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3693.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,885.08,3910.5,
SIGMOIDOSCOPY DECOMPRESSION VOLVULUS,1703042,CDM,750,RC,,,Outpatient,,,4345,3476,,3693.25,85,,,percent of total billed charges,85% of total billed charges,1086.25,100,,,fee schedule,Pays 100% Medicare OPPS,1086.25,100,,,fee schedule,Pays 100% Medicare OPPS,1086.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,885.08,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,3910.5,90,,,percent of total billed charges,90% of total billed charges,1520.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2985.02,68.7,,,percent of total billed charges,68.7% of total billed charges,3476,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,3910.5,90,,,fee schedule,Pays 90% Medicare OPPS,2520.1,58,,,percent of total billed charges,58% of total billed charges,885.08,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3693.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,885.08,3910.5,
Injections of large bowel using an endoscope,1745381,CDM,750,RC,45381,HCPCS,Outpatient,,,4345,3476,,3693.25,85,,,percent of total billed charges,85% of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,1238.25,130,,,fee schedule,Pays 130% Medicare OPPS,885.08,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,950.15,102,,,fee schedule,Pays 102% Medicare OPPS,3910.5,90,,,percent of total billed charges,90% of total billed charges,1520.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2985.02,68.7,,,percent of total billed charges,68.7% of total billed charges,3476,80,,,percent of total billed charges,80 percent of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,838.37,90,,,fee schedule,Pays 90% Medicare OPPS,2520.1,58,,,percent of total billed charges,58% of total billed charges,885.08,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,952.5,100,,,fee schedule,Pays 100% Medicare OPPS,1238.25,130,,,fee schedule,Pays 130% Medicare OPPS,3693.25,85,,,percent of total billed charges,85% of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,838.37,3910.5,
EGD WITH REMOVAL FOREIGN,1703016,CDM,750,RC,43247,HCPCS,Outpatient,,,4360,3488,,3706,85,,,percent of total billed charges,85% of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,943.93,130,,,fee schedule,Pays 130% Medicare OPPS,888.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,741.4,102,,,fee schedule,Pays 102% Medicare OPPS,3924,90,,,percent of total billed charges,90% of total billed charges,1526,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,2995.32,68.7,,,percent of total billed charges,68.7% of total billed charges,3488,80,,,percent of total billed charges,80 percent of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,654.17,90,,,fee schedule,Pays 90% Medicare OPPS,2528.8,58,,,percent of total billed charges,58% of total billed charges,888.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,726.1,100,,,fee schedule,Pays 100% Medicare OPPS,943.93,130,,,fee schedule,Pays 130% Medicare OPPS,3706,85,,,percent of total billed charges,85% of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,654.17,3924,
INSJ PICC RS&I 5YR+,1536573,CDM,360,RC,36573,HCPCS,Outpatient,,,4375,3500,,3718.75,85,,,percent of total billed charges,85% of total billed charges,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,1701.28,130,,,fee schedule,Pays 130% Medicare OPPS,891.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,1288.48,102,,,fee schedule,Pays 102% Medicare OPPS,3937.5,90,,,percent of total billed charges,90% of total billed charges,1531.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3005.63,68.7,,,percent of total billed charges,68.7% of total billed charges,3500,80,,,percent of total billed charges,80 percent of total billed charges,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,1136.89,90,,,fee schedule,Pays 90% Medicare OPPS,2537.5,58,,,percent of total billed charges,58% of total billed charges,891.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1308.68,100,,,fee schedule,Pays 100% Medicare OPPS,1701.28,130,,,fee schedule,Pays 130% Medicare OPPS,3718.75,85,,,percent of total billed charges,85% of total billed charges,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,3937.5,
FISTULA PLUG BIODESIGN G54613,1570798,CDM,272,RC,C1763,HCPCS,Outpatient,,,4375,3500,,3718.75,85,,,percent of total billed charges,85% of total billed charges,1093.75,100,,,fee schedule,Pays 100% Medicare OPPS,1093.75,100,,,fee schedule,Pays 100% Medicare OPPS,1093.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,891.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,3937.5,90,,,percent of total billed charges,90% of total billed charges,1531.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3005.63,68.7,,,percent of total billed charges,68.7% of total billed charges,3500,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,3937.5,90,,,fee schedule,Pays 90% Medicare OPPS,2537.5,58,,,percent of total billed charges,58% of total billed charges,891.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3718.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,891.19,3937.5,
CT NEEDLE BIOPSY/JT INJECT,4276360,CDM,350,RC,77012,HCPCS,Outpatient,,,4390,3512,,3731.5,85,,,percent of total billed charges,85% of total billed charges,1097.5,100,,,fee schedule,Pays 100% Medicare OPPS,1097.5,100,,,fee schedule,Pays 100% Medicare OPPS,1097.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,894.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2480.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2480.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2480.35,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2467.18,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,3951,90,,,percent of total billed charges,90% of total billed charges,1536.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3015.93,68.7,,,percent of total billed charges,68.7% of total billed charges,3512,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,3951,90,,,fee schedule,Pays 90% Medicare OPPS,2546.2,58,,,percent of total billed charges,58% of total billed charges,894.24,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3731.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,894.24,3951,
RABIES IMMUNE GLOB 150UNIT/ML 10ML VIAL,2601040,CDM,636,RC,90375,HCPCS,Both,,,4410,3528,,3748.5,85,,,percent of total billed charges,85% of total billed charges,213.24,100,,,fee schedule,Pays 100% Medicare ,213.24,100,,,fee schedule,Pays 100% Medicare ,213.24,100,,,fee schedule,Pays 100% Medicare ,361.06,130,,,fee schedule,Pays 130% Medicare OPPS,256.68,120.37,,,fee schedule,120.37% of custom fee schedule,2300.74,52.17,,,case rate,100% of BCBS case rate,2300.74,52.17,,,case rate,100% of BCBS case rate,2300.74,52.17,,,case rate,100% of BCBS case rate,2300.74,52.17,,,case rate,100% of BCBS case rate,217.5,102,,,fee schedule,Pays 102% Medicare ,3969,90,,,percent of total billed charges,90% of total billed charges,266.93,125.18,,,fee schedule,125.18% of custom fee schedule,3029.67,68.7,,,percent of total billed charges,68.7% of total billed charges,3528,80,,,percent of total billed charges,80 percent of total billed charges,213.24,100,,,fee schedule,Pays 100% Medicare ,191.91,90,,,fee schedule,Pays 90% Medicare ,2557.8,58,,,percent of total billed charges,58% of total billed charges,256.68,120.37,,,fee schedule,120.37% of custom fee schedule,277.74,100,,,fee schedule,Pays 100% Medicare ,361.06,130,,,fee schedule,Pays 130% Medicare OPPS,3748.5,85,,,percent of total billed charges,85% of total billed charges,213.24,100,,,fee schedule,Pays 100% Medicare ,191.91,3969,
Diagnostic examination of large bowel using an endoscope which is inserted through abdominal opening,1744388,CDM,750,RC,44388,HCPCS,Outpatient,,,4595,3676,,3905.75,85,,,percent of total billed charges,85% of total billed charges,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,950.25,130,,,fee schedule,Pays 130% Medicare OPPS,936,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,727.13,102,,,fee schedule,Pays 102% Medicare OPPS,4135.5,90,,,percent of total billed charges,90% of total billed charges,1608.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3156.77,68.7,,,percent of total billed charges,68.7% of total billed charges,3676,80,,,percent of total billed charges,80 percent of total billed charges,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,641.59,90,,,fee schedule,Pays 90% Medicare OPPS,2665.1,58,,,percent of total billed charges,58% of total billed charges,936,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,730.96,100,,,fee schedule,Pays 100% Medicare OPPS,950.25,130,,,fee schedule,Pays 130% Medicare OPPS,3905.75,85,,,percent of total billed charges,85% of total billed charges,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,641.59,4135.5,
DIAGNOSTIC SIGMODOSCOPY,1745330,CDM,750,RC,,,Outpatient,,,4595,3676,,3905.75,85,,,percent of total billed charges,85% of total billed charges,1148.75,100,,,fee schedule,Pays 100% Medicare OPPS,1148.75,100,,,fee schedule,Pays 100% Medicare OPPS,1148.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,936,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,4135.5,90,,,percent of total billed charges,90% of total billed charges,1608.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3156.77,68.7,,,percent of total billed charges,68.7% of total billed charges,3676,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,4135.5,90,,,fee schedule,Pays 90% Medicare OPPS,2665.1,58,,,percent of total billed charges,58% of total billed charges,936,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3905.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,936,4135.5,
Removing an indwelling ureteral stent by cystoscopy,1552310,CDM,790,RC,52310,HCPCS,Outpatient,,,4610,3688,,3918.5,85,,,percent of total billed charges,85% of total billed charges,1608.44,100,,,fee schedule,Pays 100% Medicare OPPS,1608.44,100,,,fee schedule,Pays 100% Medicare OPPS,1608.44,100,,,fee schedule,Pays 100% Medicare OPPS,2120.96,130,,,fee schedule,Pays 130% Medicare OPPS,939.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,1640.61,102,,,fee schedule,Pays 102% Medicare OPPS,4149,90,,,percent of total billed charges,90% of total billed charges,1613.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3167.07,68.7,,,percent of total billed charges,68.7% of total billed charges,3688,80,,,percent of total billed charges,80 percent of total billed charges,1608.44,100,,,fee schedule,Pays 100% Medicare OPPS,1447.59,90,,,fee schedule,Pays 90% Medicare OPPS,2673.8,58,,,percent of total billed charges,58% of total billed charges,939.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1631.51,100,,,fee schedule,Pays 100% Medicare OPPS,2120.96,130,,,fee schedule,Pays 130% Medicare OPPS,3918.5,85,,,percent of total billed charges,85% of total billed charges,1608.44,100,,,fee schedule,Pays 100% Medicare OPPS,939.06,4149,
FISTULA PLUG BIODESIGN G53614,1570799,CDM,272,RC,C1763,HCPCS,Outpatient,,,4625,3700,,3931.25,85,,,percent of total billed charges,85% of total billed charges,1156.25,100,,,fee schedule,Pays 100% Medicare OPPS,1156.25,100,,,fee schedule,Pays 100% Medicare OPPS,1156.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,942.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,4162.5,90,,,percent of total billed charges,90% of total billed charges,1618.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3177.38,68.7,,,percent of total billed charges,68.7% of total billed charges,3700,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,4162.5,90,,,fee schedule,Pays 90% Medicare OPPS,2682.5,58,,,percent of total billed charges,58% of total billed charges,942.11,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3931.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,942.11,4162.5,
ESOPHAGOSCOPY FLEX BIOSPSY,1743202,CDM,750,RC,43202,HCPCS,Outpatient,,,4690,3752,,3986.5,85,,,percent of total billed charges,85% of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1991.42,130,,,fee schedule,Pays 130% Medicare OPPS,955.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,1488.23,102,,,fee schedule,Pays 102% Medicare OPPS,4221,90,,,percent of total billed charges,90% of total billed charges,1641.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3222.03,68.7,,,percent of total billed charges,68.7% of total billed charges,3752,80,,,percent of total billed charges,80 percent of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1313.14,90,,,fee schedule,Pays 90% Medicare OPPS,2720.2,58,,,percent of total billed charges,58% of total billed charges,955.35,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1531.86,100,,,fee schedule,Pays 100% Medicare OPPS,1991.42,130,,,fee schedule,Pays 130% Medicare OPPS,3986.5,85,,,percent of total billed charges,85% of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,4221,
EGD WITH BIOPSY,1703005,CDM,750,RC,,,Outpatient,,,4695,3756,,3990.75,85,,,percent of total billed charges,85% of total billed charges,1173.75,100,,,fee schedule,Pays 100% Medicare OPPS,1173.75,100,,,fee schedule,Pays 100% Medicare OPPS,1173.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,956.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,4225.5,90,,,percent of total billed charges,90% of total billed charges,1643.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3225.47,68.7,,,percent of total billed charges,68.7% of total billed charges,3756,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,4225.5,90,,,fee schedule,Pays 90% Medicare OPPS,2723.1,58,,,percent of total billed charges,58% of total billed charges,956.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3990.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,956.37,4225.5,
EGD WITH BALLOON DIALITAT,1703015,CDM,750,RC,,,Outpatient,,,4695,3756,,3990.75,85,,,percent of total billed charges,85% of total billed charges,1173.75,100,,,fee schedule,Pays 100% Medicare OPPS,1173.75,100,,,fee schedule,Pays 100% Medicare OPPS,1173.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,956.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,4225.5,90,,,percent of total billed charges,90% of total billed charges,1643.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3225.47,68.7,,,percent of total billed charges,68.7% of total billed charges,3756,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,4225.5,90,,,fee schedule,Pays 90% Medicare OPPS,2723.1,58,,,percent of total billed charges,58% of total billed charges,956.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,3990.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,956.37,4225.5,
EGD GUIDE WIRE INSERTION,1743248,CDM,750,RC,43248,HCPCS,Outpatient,,,4695,3756,,3990.75,85,,,percent of total billed charges,85% of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,943.93,130,,,fee schedule,Pays 130% Medicare OPPS,956.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,741.4,102,,,fee schedule,Pays 102% Medicare OPPS,4225.5,90,,,percent of total billed charges,90% of total billed charges,1643.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3225.47,68.7,,,percent of total billed charges,68.7% of total billed charges,3756,80,,,percent of total billed charges,80 percent of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,654.17,90,,,fee schedule,Pays 90% Medicare OPPS,2723.1,58,,,percent of total billed charges,58% of total billed charges,956.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,726.1,100,,,fee schedule,Pays 100% Medicare OPPS,943.93,130,,,fee schedule,Pays 130% Medicare OPPS,3990.75,85,,,percent of total billed charges,85% of total billed charges,726.87,100,,,fee schedule,Pays 100% Medicare OPPS,654.17,4225.5,
SIGMOIDOSCOPE W/SUBMUC INJ,1745335,CDM,750,RC,45335,HCPCS,Outpatient,,,4695,3756,,3990.75,85,,,percent of total billed charges,85% of total billed charges,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,950.25,130,,,fee schedule,Pays 130% Medicare OPPS,956.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,727.13,102,,,fee schedule,Pays 102% Medicare OPPS,4225.5,90,,,percent of total billed charges,90% of total billed charges,1643.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3225.47,68.7,,,percent of total billed charges,68.7% of total billed charges,3756,80,,,percent of total billed charges,80 percent of total billed charges,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,641.59,90,,,fee schedule,Pays 90% Medicare OPPS,2723.1,58,,,percent of total billed charges,58% of total billed charges,956.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,730.96,100,,,fee schedule,Pays 100% Medicare OPPS,950.25,130,,,fee schedule,Pays 130% Medicare OPPS,3990.75,85,,,percent of total billed charges,85% of total billed charges,712.88,100,,,fee schedule,Pays 100% Medicare OPPS,641.59,4225.5,
Tying of large bowel using an endoscope,1745398,CDM,750,RC,45398,HCPCS,Outpatient,,,4695,3756,,3990.75,85,,,percent of total billed charges,85% of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,1238.25,130,,,fee schedule,Pays 130% Medicare OPPS,956.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,950.15,102,,,fee schedule,Pays 102% Medicare OPPS,4225.5,90,,,percent of total billed charges,90% of total billed charges,1643.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3225.47,68.7,,,percent of total billed charges,68.7% of total billed charges,3756,80,,,percent of total billed charges,80 percent of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,838.37,90,,,fee schedule,Pays 90% Medicare OPPS,2723.1,58,,,percent of total billed charges,58% of total billed charges,956.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,952.5,100,,,fee schedule,Pays 100% Medicare OPPS,1238.25,130,,,fee schedule,Pays 130% Medicare OPPS,3990.75,85,,,percent of total billed charges,85% of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,838.37,4225.5,
SMALL INTESTINAL ENDO,1744376,CDM,750,RC,44376,HCPCS,Outpatient,,,4725,3780,,4016.25,85,,,percent of total billed charges,85% of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1991.42,130,,,fee schedule,Pays 130% Medicare OPPS,962.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,1488.23,102,,,fee schedule,Pays 102% Medicare OPPS,4252.5,90,,,percent of total billed charges,90% of total billed charges,1653.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3246.08,68.7,,,percent of total billed charges,68.7% of total billed charges,3780,80,,,percent of total billed charges,80 percent of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1313.14,90,,,fee schedule,Pays 90% Medicare OPPS,2740.5,58,,,percent of total billed charges,58% of total billed charges,962.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1531.86,100,,,fee schedule,Pays 100% Medicare OPPS,1991.42,130,,,fee schedule,Pays 130% Medicare OPPS,4016.25,85,,,percent of total billed charges,85% of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,4252.5,
Image of the heart to assess perfusion,4578480,CDM,341,RC,78452,HCPCS,Outpatient,,,4725,3780,,4016.25,85,,,percent of total billed charges,85% of total billed charges,1173.9,100,,,fee schedule,Pays 100% Medicare OPPS,1173.9,100,,,fee schedule,Pays 100% Medicare OPPS,1173.9,100,,,fee schedule,Pays 100% Medicare OPPS,1517.67,130,,,fee schedule,Pays 130% Medicare OPPS,962.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,1197.38,102,,,fee schedule,Pays 102% Medicare OPPS,4252.5,90,,,percent of total billed charges,90% of total billed charges,1653.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3246.08,68.7,,,percent of total billed charges,68.7% of total billed charges,3780,80,,,percent of total billed charges,80 percent of total billed charges,1173.9,100,,,fee schedule,Pays 100% Medicare OPPS,1056.5,90,,,fee schedule,Pays 90% Medicare OPPS,2740.5,58,,,percent of total billed charges,58% of total billed charges,962.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1167.44,100,,,fee schedule,Pays 100% Medicare OPPS,1517.67,130,,,fee schedule,Pays 130% Medicare OPPS,4016.25,85,,,percent of total billed charges,85% of total billed charges,1173.9,100,,,fee schedule,Pays 100% Medicare OPPS,962.48,4252.5,
CTA ABDOMEN AND PELVIS,4274174,CDM,352,RC,74174,HCPCS,Outpatient,,,4785,3828,,4067.25,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,974.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2703.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2703.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2703.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2689.17,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,4306.5,90,,,percent of total billed charges,90% of total billed charges,1674.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3287.3,68.7,,,percent of total billed charges,68.7% of total billed charges,3828,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,2775.3,58,,,percent of total billed charges,58% of total billed charges,974.7,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,4067.25,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,4306.5,
DISLOC SHOULDER W ANES,2023655,CDM,450,RC,23655,HCPCS,Outpatient,,,4815,3852,,4092.75,85,,,percent of total billed charges,85% of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1640.3,130,,,fee schedule,Pays 130% Medicare OPPS,980.82,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,1276.23,102,,,fee schedule,Pays 102% Medicare OPPS,4333.5,90,,,percent of total billed charges,90% of total billed charges,1685.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3307.91,68.7,,,percent of total billed charges,68.7% of total billed charges,3852,80,,,percent of total billed charges,80 percent of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1126.08,90,,,fee schedule,Pays 90% Medicare OPPS,2792.7,58,,,percent of total billed charges,58% of total billed charges,980.82,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1261.77,100,,,fee schedule,Pays 100% Medicare OPPS,1640.3,130,,,fee schedule,Pays 130% Medicare OPPS,4092.75,85,,,percent of total billed charges,85% of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,980.82,4333.5,
EGD WITH CONTROL BLEEDING,1703017,CDM,750,RC,,,Outpatient,,,4875,3900,,4143.75,85,,,percent of total billed charges,85% of total billed charges,1218.75,100,,,fee schedule,Pays 100% Medicare OPPS,1218.75,100,,,fee schedule,Pays 100% Medicare OPPS,1218.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,993.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,4387.5,90,,,percent of total billed charges,90% of total billed charges,1706.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3349.13,68.7,,,percent of total billed charges,68.7% of total billed charges,3900,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,4387.5,90,,,fee schedule,Pays 90% Medicare OPPS,2827.5,58,,,percent of total billed charges,58% of total billed charges,993.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4143.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,993.04,4387.5,
EXCISION TUMOR UPPER ARM < 3 CM,1724075,CDM,360,RC,24075,HCPCS,Outpatient,,,4965,3972,,4220.25,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,1011.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,1289.21,102,,,fee schedule,Pays 102% Medicare OPPS,4468.5,90,,,percent of total billed charges,90% of total billed charges,1737.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3410.96,68.7,,,percent of total billed charges,68.7% of total billed charges,3972,80,,,percent of total billed charges,80 percent of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1137.55,90,,,fee schedule,Pays 90% Medicare OPPS,2879.7,58,,,percent of total billed charges,58% of total billed charges,1011.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1318.97,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,4220.25,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,4468.5,
REMOVAL OF TUNNELED CVAD W PORT/PUMP,1736590,CDM,360,RC,36590,HCPCS,Outpatient,,,4965,3972,,4220.25,85,,,percent of total billed charges,85% of total billed charges,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,1701.28,130,,,fee schedule,Pays 130% Medicare OPPS,1011.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,1288.48,102,,,fee schedule,Pays 102% Medicare OPPS,4468.5,90,,,percent of total billed charges,90% of total billed charges,1737.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3410.96,68.7,,,percent of total billed charges,68.7% of total billed charges,3972,80,,,percent of total billed charges,80 percent of total billed charges,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,1136.89,90,,,fee schedule,Pays 90% Medicare OPPS,2879.7,58,,,percent of total billed charges,58% of total billed charges,1011.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1308.68,100,,,fee schedule,Pays 100% Medicare OPPS,1701.28,130,,,fee schedule,Pays 130% Medicare OPPS,4220.25,85,,,percent of total billed charges,85% of total billed charges,1263.21,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,4468.5,
DISLOC ELBOW TX W ANEST,2024605,CDM,450,RC,24605,HCPCS,Outpatient,,,4965,3972,,4220.25,85,,,percent of total billed charges,85% of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1640.3,130,,,fee schedule,Pays 130% Medicare ,1011.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,1276.23,102,,,fee schedule,Pays 102% Medicare OPPS,4468.5,90,,,percent of total billed charges,90% of total billed charges,1737.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3410.96,68.7,,,percent of total billed charges,68.7% of total billed charges,3972,80,,,percent of total billed charges,80 percent of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1126.08,90,,,fee schedule,Pays 90% Medicare OPPS,2879.7,58,,,percent of total billed charges,58% of total billed charges,1011.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1261.77,100,,,fee schedule,Pays 100% Medicare OPPS,1640.3,130,,,fee schedule,Pays 130% Medicare ,4220.25,85,,,percent of total billed charges,85% of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1011.37,4468.5,
CHANGE OF URETER TUBE STINT,2050688,CDM,761,RC,50688,HCPCS,Outpatient,,,4965,3972,,4220.25,85,,,percent of total billed charges,85% of total billed charges,1608.44,100,,,fee schedule,Pays 100% Medicare OPPS,1608.44,100,,,fee schedule,Pays 100% Medicare OPPS,1608.44,100,,,fee schedule,Pays 100% Medicare OPPS,2120.96,130,,,fee schedule,Pays 130% Medicare ,1011.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,1640.61,102,,,fee schedule,Pays 102% Medicare OPPS,4468.5,90,,,percent of total billed charges,90% of total billed charges,1737.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3410.96,68.7,,,percent of total billed charges,68.7% of total billed charges,3972,80,,,percent of total billed charges,80 percent of total billed charges,1608.44,100,,,fee schedule,Pays 100% Medicare OPPS,1447.59,90,,,fee schedule,Pays 90% Medicare OPPS,2879.7,58,,,percent of total billed charges,58% of total billed charges,1011.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1631.51,100,,,fee schedule,Pays 100% Medicare OPPS,2120.96,130,,,fee schedule,Pays 130% Medicare ,4220.25,85,,,percent of total billed charges,85% of total billed charges,1608.44,100,,,fee schedule,Pays 100% Medicare OPPS,1011.37,4468.5,
HERNIA ECHO 2 POSITIONING SYSTEM 5991520,1570384,CDM,278,RC,C1781,HCPCS,Both,,,5000,4000,,4250,85,,,percent of total billed charges,85% of total billed charges,1250,100,,,fee schedule,Pays 100% Medicare ,1250,100,,,fee schedule,Pays 100% Medicare ,1250,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,1018.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2608.55,52.17,,,case rate,100% of BCBS case rate,2608.55,52.17,,,case rate,100% of BCBS case rate,2608.55,52.17,,,case rate,100% of BCBS case rate,2608.55,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,4500,90,,,percent of total billed charges,90% of total billed charges,1750,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3435,68.7,,,percent of total billed charges,68.7% of total billed charges,4000,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,4500,90,,,fee schedule,Pays 90% Medicare ,2900,58,,,percent of total billed charges,58% of total billed charges,1018.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4250,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1018.5,4500,
HERNIA XENMATRIX AB SURGICAL GRAFT,1570385,CDM,278,RC,C1781,HCPCS,Both,,,5000,4000,,4250,85,,,percent of total billed charges,85% of total billed charges,1250,100,,,fee schedule,Pays 100% Medicare ,1250,100,,,fee schedule,Pays 100% Medicare ,1250,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,1018.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2608.55,52.17,,,case rate,100% of BCBS case rate,2608.55,52.17,,,case rate,100% of BCBS case rate,2608.55,52.17,,,case rate,100% of BCBS case rate,2608.55,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,4500,90,,,percent of total billed charges,90% of total billed charges,1750,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3435,68.7,,,percent of total billed charges,68.7% of total billed charges,4000,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,4500,90,,,fee schedule,Pays 90% Medicare ,2900,58,,,percent of total billed charges,58% of total billed charges,1018.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4250,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1018.5,4500,
MARKER BREAST BIOZORB LP 2CMX2CMX1CM,1570882,CDM,360,RC,C9728,HCPCS,Outpatient,,,5048,4038.4,,4290.8,85,,,percent of total billed charges,85% of total billed charges,1134.35,100,,,fee schedule,Pays 100% Medicare OPPS,1134.35,100,,,fee schedule,Pays 100% Medicare OPPS,1134.35,100,,,fee schedule,Pays 100% Medicare OPPS,1532.99,130,,,fee schedule,Pays 130% Medicare OPPS,1028.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,1157.05,102,,,fee schedule,Pays 102% Medicare OPPS,4543.2,90,,,percent of total billed charges,90% of total billed charges,1766.8,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3467.98,68.7,,,percent of total billed charges,68.7% of total billed charges,4038.4,80,,,percent of total billed charges,80 percent of total billed charges,1134.35,100,,,fee schedule,Pays 100% Medicare OPPS,1020.92,90,,,fee schedule,Pays 90% Medicare OPPS,2927.84,58,,,percent of total billed charges,58% of total billed charges,1028.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1179.22,100,,,fee schedule,Pays 100% Medicare OPPS,1532.99,130,,,fee schedule,Pays 130% Medicare OPPS,4290.8,85,,,percent of total billed charges,85% of total billed charges,1134.35,100,,,fee schedule,Pays 100% Medicare OPPS,1020.92,4543.2,
MRI FACIAL ORBITS FACE W/O,4400001,CDM,611,RC,70540,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
MRI of brain stem without dye,4400002,CDM,611,RC,70551,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
MRA NECK W/O,4400003,CDM,615,RC,70547,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
MRI of brain stem without dye,4400009,CDM,611,RC,70551,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
MRA PITUITARY WITH CONTRA,4400010,CDM,610,RC,70544,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
MRI UPR EXT/NON JNT-LEFT W/O,4400012,CDM,610,RC,73218,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
MRI of upper extremity without dye,4400013,CDM,610,RC,73221,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
MRI UPPER EXTREMITY-LEFT WITH,4400015,CDM,610,RC,73219,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,4585.5,
MRI of leg without dye,4400016,CDM,610,RC,73718,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
MRI LOWER EXT NON JNT W/WO LT,4400017,CDM,610,RC,73720,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,4585.5,
MRI of lower extremity joint (knee/ankle) without dye,4400018,CDM,610,RC,73721,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
MRI of lower extremity joint (knee/ankle) with and without dye,4400019,CDM,610,RC,73723,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,4585.5,
MRI of lower extremity joint (knee/ankle) without dye,4400020,CDM,610,RC,73721,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
MRI of lower extremity joint (knee/ankle) with dye,4400021,CDM,610,RC,73722,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,642.67,100,,,fee schedule,Pays 100% Medicare OPPS,642.67,100,,,fee schedule,Pays 100% Medicare OPPS,642.67,100,,,fee schedule,Pays 100% Medicare OPPS,847,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,655.53,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,642.67,100,,,fee schedule,Pays 100% Medicare OPPS,578.41,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,651.54,100,,,fee schedule,Pays 100% Medicare OPPS,847,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,642.67,100,,,fee schedule,Pays 100% Medicare OPPS,578.41,4585.5,
MRI of lower extremity joint (knee/ankle) without dye,4400023,CDM,610,RC,73721,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
MRI of pelvis without dye,4400025,CDM,610,RC,72195,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
MRI of abdomen without dye,4400026,CDM,610,RC,74181,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
MRI LOWER EXT NON JNT W LT,4400027,CDM,610,RC,73719,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,4585.5,
MRA LOWER EXT W/O CONTRAST,4408913,CDM,610,RC,73725,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,1273.75,100,,,fee schedule,Pays 100% Medicare OPPS,1273.75,100,,,fee schedule,Pays 100% Medicare OPPS,1273.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,4585.5,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4330.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1037.85,4585.5,
MRI TMJ,4470336,CDM,610,RC,70336,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
MRI ORBITS W/O,4470540,CDM,611,RC,70540,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
MRA HEAD W/OUT,4470544,CDM,615,RC,70544,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
MRI NECK W/0,4470547,CDM,610,RC,70540,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
MRI of brain stem without dye,4470551,CDM,611,RC,70551,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
MRI BRAIN W/CONTRAST,4470552,CDM,611,RC,70552,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,4585.5,
MRI CHST/HILAR/MEDIASTINA,4471550,CDM,610,RC,71550,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
MRA CHEST,4471555,CDM,610,RC,71555,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,1273.75,100,,,fee schedule,Pays 100% Medicare OPPS,1273.75,100,,,fee schedule,Pays 100% Medicare OPPS,1273.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,4585.5,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4330.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1037.85,4585.5,
MRI of the neck or spine without dye,4472141,CDM,612,RC,72141,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
MRI CERVICAL SPINE W/CON,4472142,CDM,612,RC,72142,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,4585.5,
MRI of chest and spine without dye,4472146,CDM,612,RC,72146,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
MRI scan of lower spinal canal,4472148,CDM,612,RC,72148,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
MRI LUMBAR SPINE WITH,4472149,CDM,612,RC,72149,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,4585.5,
MRI of chest and spine with and without dye,4472157,CDM,612,RC,72157,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,4585.5,
MRI PELVIC W/CONTRAST,4472196,CDM,612,RC,72196,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,4585.5,
MRI UPPER EXT NON-JT WITHOUT,4473218,CDM,610,RC,73220,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,4585.5,
MRI of upper extremity without dye,4473221,CDM,610,RC,73221,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
MRI UPPER EXT JOINT W/CONTRAST,4473222,CDM,610,RC,73222,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,642.67,100,,,fee schedule,Pays 100% Medicare OPPS,642.67,100,,,fee schedule,Pays 100% Medicare OPPS,642.67,100,,,fee schedule,Pays 100% Medicare OPPS,847,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,655.53,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,642.67,100,,,fee schedule,Pays 100% Medicare OPPS,578.41,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,651.54,100,,,fee schedule,Pays 100% Medicare OPPS,847,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,642.67,100,,,fee schedule,Pays 100% Medicare OPPS,578.41,4585.5,
MRI UPPER EXTREMITY-RIGHT WITH,4473225,CDM,610,RC,73219,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,4585.5,
MRI of leg without dye,4473718,CDM,610,RC,73718,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
MRI LOWER EXT NON JNT W RT,4473719,CDM,610,RC,73719,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,4585.5,
MRI LOWER EXT NON JNT W/WO RT,4473720,CDM,610,RC,73720,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,4585.5,
MRI of lower extremity joint (knee/ankle) without dye,4473721,CDM,610,RC,73721,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
MRI of lower extremity joint (knee/ankle) with dye,4473722,CDM,610,RC,73722,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,642.67,100,,,fee schedule,Pays 100% Medicare OPPS,642.67,100,,,fee schedule,Pays 100% Medicare OPPS,642.67,100,,,fee schedule,Pays 100% Medicare OPPS,847,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,655.53,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,642.67,100,,,fee schedule,Pays 100% Medicare OPPS,578.41,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,651.54,100,,,fee schedule,Pays 100% Medicare OPPS,847,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,642.67,100,,,fee schedule,Pays 100% Medicare OPPS,578.41,4585.5,
MRI of abdomen without dye,4474181,CDM,610,RC,74181,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
MRI ABD W/ CONTRAST,4474182,CDM,610,RC,74182,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,4585.5,
MRA ABDOMEN,4474185,CDM,610,RC,74185,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,1273.75,100,,,fee schedule,Pays 100% Medicare OPPS,1273.75,100,,,fee schedule,Pays 100% Medicare OPPS,1273.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,4585.5,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4330.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1037.85,4585.5,
MRI MYOCARDIUM W/O CONTRA,4475552,CDM,610,RC,75557,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare ,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare ,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
MRI BONE MARROW BLOOD,4476400,CDM,610,RC,77084,HCPCS,Outpatient,,,5095,4076,,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2878.68,56.5,,,percent of total billed charges,56.5 percent of total billed charges,2863.39,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,4585.5,90,,,percent of total billed charges,90% of total billed charges,1783.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3500.27,68.7,,,percent of total billed charges,68.7% of total billed charges,4076,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,2955.1,58,,,percent of total billed charges,58% of total billed charges,1037.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,4330.75,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,4585.5,
GRAFTJACKET MATRIX,1570055,CDM,636,RC,Q4107,HCPCS,Both,,,5125,4100,,4356.25,85,,,percent of total billed charges,85% of total billed charges,1281.25,100,,,fee schedule,Pays 100% Medicare ,1281.25,100,,,fee schedule,Pays 100% Medicare ,1281.25,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,1043.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2673.76,52.17,,,case rate,100% of BCBS case rate,2673.76,52.17,,,case rate,100% of BCBS case rate,2673.76,52.17,,,case rate,100% of BCBS case rate,2673.76,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,4612.5,90,,,percent of total billed charges,90% of total billed charges,1793.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3520.88,68.7,,,percent of total billed charges,68.7% of total billed charges,4100,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,4612.5,90,,,fee schedule,Pays 90% Medicare ,2972.5,58,,,percent of total billed charges,58% of total billed charges,1043.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4356.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1043.96,4612.5,
BIOPSY BREAST INCLUDING US GUIDANNCE,4619083,CDM,761,RC,19083,HCPCS,Outpatient,,,5130,4104,,4360.5,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,1044.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,1289.21,102,,,fee schedule,Pays 102% Medicare OPPS,4617,90,,,percent of total billed charges,90% of total billed charges,1795.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3524.31,68.7,,,percent of total billed charges,68.7% of total billed charges,4104,80,,,percent of total billed charges,80 percent of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1137.55,90,,,fee schedule,Pays 90% Medicare OPPS,2975.4,58,,,percent of total billed charges,58% of total billed charges,1044.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1318.97,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,4360.5,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1044.98,4617,
MARKER BREAST BIOZORB LP 2CMX3CMX1CM,1570883,CDM,360,RC,C9728,HCPCS,Outpatient,,,5175,4140,,4398.75,85,,,percent of total billed charges,85% of total billed charges,1134.35,100,,,fee schedule,Pays 100% Medicare OPPS,1134.35,100,,,fee schedule,Pays 100% Medicare OPPS,1134.35,100,,,fee schedule,Pays 100% Medicare OPPS,1532.99,130,,,fee schedule,Pays 130% Medicare OPPS,1054.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,1157.05,102,,,fee schedule,Pays 102% Medicare OPPS,4657.5,90,,,percent of total billed charges,90% of total billed charges,1811.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3555.23,68.7,,,percent of total billed charges,68.7% of total billed charges,4140,80,,,percent of total billed charges,80 percent of total billed charges,1134.35,100,,,fee schedule,Pays 100% Medicare OPPS,1020.92,90,,,fee schedule,Pays 90% Medicare OPPS,3001.5,58,,,percent of total billed charges,58% of total billed charges,1054.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1179.22,100,,,fee schedule,Pays 100% Medicare OPPS,1532.99,130,,,fee schedule,Pays 130% Medicare OPPS,4398.75,85,,,percent of total billed charges,85% of total billed charges,1134.35,100,,,fee schedule,Pays 100% Medicare OPPS,1020.92,4657.5,
MARKER BREAST TISSUE BIOZORB 2CM X 2CM,1570880,CDM,360,RC,C9728,HCPCS,Outpatient,,,5225,4180,,4441.25,85,,,percent of total billed charges,85% of total billed charges,1134.35,100,,,fee schedule,Pays 100% Medicare OPPS,1134.35,100,,,fee schedule,Pays 100% Medicare OPPS,1134.35,100,,,fee schedule,Pays 100% Medicare OPPS,1532.99,130,,,fee schedule,Pays 130% Medicare OPPS,1064.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,1157.05,102,,,fee schedule,Pays 102% Medicare OPPS,4702.5,90,,,percent of total billed charges,90% of total billed charges,1828.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3589.58,68.7,,,percent of total billed charges,68.7% of total billed charges,4180,80,,,percent of total billed charges,80 percent of total billed charges,1134.35,100,,,fee schedule,Pays 100% Medicare OPPS,1020.92,90,,,fee schedule,Pays 90% Medicare OPPS,3030.5,58,,,percent of total billed charges,58% of total billed charges,1064.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1179.22,100,,,fee schedule,Pays 100% Medicare OPPS,1532.99,130,,,fee schedule,Pays 130% Medicare OPPS,4441.25,85,,,percent of total billed charges,85% of total billed charges,1134.35,100,,,fee schedule,Pays 100% Medicare OPPS,1020.92,4702.5,
MARKER BREAST TISSUE BIOZORB 2CM X 3CM,1570881,CDM,360,RC,C9728,HCPCS,Outpatient,,,5225,4180,,4441.25,85,,,percent of total billed charges,85% of total billed charges,1134.35,100,,,fee schedule,Pays 100% Medicare OPPS,1134.35,100,,,fee schedule,Pays 100% Medicare OPPS,1134.35,100,,,fee schedule,Pays 100% Medicare OPPS,1532.99,130,,,fee schedule,Pays 130% Medicare OPPS,1064.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,1157.05,102,,,fee schedule,Pays 102% Medicare OPPS,4702.5,90,,,percent of total billed charges,90% of total billed charges,1828.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3589.58,68.7,,,percent of total billed charges,68.7% of total billed charges,4180,80,,,percent of total billed charges,80 percent of total billed charges,1134.35,100,,,fee schedule,Pays 100% Medicare OPPS,1020.92,90,,,fee schedule,Pays 90% Medicare OPPS,3030.5,58,,,percent of total billed charges,58% of total billed charges,1064.33,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1179.22,100,,,fee schedule,Pays 100% Medicare OPPS,1532.99,130,,,fee schedule,Pays 130% Medicare OPPS,4441.25,85,,,percent of total billed charges,85% of total billed charges,1134.35,100,,,fee schedule,Pays 100% Medicare OPPS,1020.92,4702.5,
DESTROY INTERNAL HEMORRHOIDS,1746930,CDM,750,RC,46930,HCPCS,Outpatient,,,5250,4200,,4462.5,85,,,percent of total billed charges,85% of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,1238.25,130,,,fee schedule,Pays 130% Medicare OPPS,1069.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,950.15,102,,,fee schedule,Pays 102% Medicare OPPS,4725,90,,,percent of total billed charges,90% of total billed charges,1837.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3606.75,68.7,,,percent of total billed charges,68.7% of total billed charges,4200,80,,,percent of total billed charges,80 percent of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,838.37,90,,,fee schedule,Pays 90% Medicare OPPS,3045,58,,,percent of total billed charges,58% of total billed charges,1069.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,952.5,100,,,fee schedule,Pays 100% Medicare OPPS,1238.25,130,,,fee schedule,Pays 130% Medicare OPPS,4462.5,85,,,percent of total billed charges,85% of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,838.37,4725,
MARKER BREAST TISSUE BIOZORB 3CM X 3CM,1570884,CDM,360,RC,C9728,HCPCS,Outpatient,,,5275,4220,,4483.75,85,,,percent of total billed charges,85% of total billed charges,1134.35,100,,,fee schedule,Pays 100% Medicare OPPS,1134.35,100,,,fee schedule,Pays 100% Medicare OPPS,1134.35,100,,,fee schedule,Pays 100% Medicare OPPS,1532.99,130,,,fee schedule,Pays 130% Medicare OPPS,1074.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,1157.05,102,,,fee schedule,Pays 102% Medicare OPPS,4747.5,90,,,percent of total billed charges,90% of total billed charges,1846.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3623.93,68.7,,,percent of total billed charges,68.7% of total billed charges,4220,80,,,percent of total billed charges,80 percent of total billed charges,1134.35,100,,,fee schedule,Pays 100% Medicare OPPS,1020.92,90,,,fee schedule,Pays 90% Medicare OPPS,3059.5,58,,,percent of total billed charges,58% of total billed charges,1074.52,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1179.22,100,,,fee schedule,Pays 100% Medicare OPPS,1532.99,130,,,fee schedule,Pays 130% Medicare OPPS,4483.75,85,,,percent of total billed charges,85% of total billed charges,1134.35,100,,,fee schedule,Pays 100% Medicare OPPS,1020.92,4747.5,
SFT TISSUE BX NECK/THORAX,4621550,CDM,761,RC,21550,HCPCS,Outpatient,,,5315,4252,,4517.75,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,1082.67,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,1289.21,102,,,fee schedule,Pays 102% Medicare OPPS,4783.5,90,,,percent of total billed charges,90% of total billed charges,1860.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3651.41,68.7,,,percent of total billed charges,68.7% of total billed charges,4252,80,,,percent of total billed charges,80 percent of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1137.55,90,,,fee schedule,Pays 90% Medicare OPPS,3082.7,58,,,percent of total billed charges,58% of total billed charges,1082.67,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1318.97,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,4517.75,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1082.67,4783.5,
CL TX NASAL SEPTAL FX,2021337,CDM,450,RC,21337,HCPCS,Outpatient,,,5375,4300,,4568.75,85,,,percent of total billed charges,85% of total billed charges,2457.53,100,,,fee schedule,Pays 100% Medicare OPPS,2457.53,100,,,fee schedule,Pays 100% Medicare OPPS,2457.53,100,,,fee schedule,Pays 100% Medicare OPPS,3253.15,130,,,fee schedule,Pays 130% Medicare OPPS,1094.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2506.67,102,,,fee schedule,Pays 102% Medicare OPPS,4837.5,90,,,percent of total billed charges,90% of total billed charges,1881.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3692.63,68.7,,,percent of total billed charges,68.7% of total billed charges,4300,80,,,percent of total billed charges,80 percent of total billed charges,2457.53,100,,,fee schedule,Pays 100% Medicare OPPS,2211.77,90,,,fee schedule,Pays 90% Medicare OPPS,3117.5,58,,,percent of total billed charges,58% of total billed charges,1094.89,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2502.42,100,,,fee schedule,Pays 100% Medicare OPPS,3253.15,130,,,fee schedule,Pays 130% Medicare OPPS,4568.75,85,,,percent of total billed charges,85% of total billed charges,2457.53,100,,,fee schedule,Pays 100% Medicare OPPS,1094.89,4837.5,
............MRA LOWER EXT JNT W/CONTRAST,4473725,CDM,610,RC,C8912,HCPCS,Outpatient,,,5415,4332,,4602.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1103.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3059.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3059.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3059.48,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3043.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,4873.5,90,,,percent of total billed charges,90% of total billed charges,1895.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3720.11,68.7,,,percent of total billed charges,68.7% of total billed charges,4332,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,3140.7,58,,,percent of total billed charges,58% of total billed charges,1103.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,4602.75,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,4873.5,
CTA AORTA W/RUNOFF W/WO,4275635,CDM,352,RC,75635,HCPCS,Outpatient,,,5460,4368,,4641,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,206.21,130,,,fee schedule,Pays 130% Medicare OPPS,1112.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3084.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3084.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3084.9,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3068.52,56.5,,,percent of total billed charges,56.5 percent of total billed charges,163.67,102,,,fee schedule,Pays 102% Medicare OPPS,4914,90,,,percent of total billed charges,90% of total billed charges,1911,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3751.02,68.7,,,percent of total billed charges,68.7% of total billed charges,4368,80,,,percent of total billed charges,80 percent of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,90,,,fee schedule,Pays 90% Medicare OPPS,3166.8,58,,,percent of total billed charges,58% of total billed charges,1112.2,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,158.62,100,,,fee schedule,Pays 100% Medicare OPPS,206.21,130,,,fee schedule,Pays 130% Medicare OPPS,4641,85,,,percent of total billed charges,85% of total billed charges,160.46,100,,,fee schedule,Pays 100% Medicare OPPS,144.41,4914,
COLONOSCOPY TUMOR/POLY RM,1703026,CDM,750,RC,,,Outpatient,,,5520,4416,,4692,85,,,percent of total billed charges,85% of total billed charges,1380,100,,,fee schedule,Pays 100% Medicare OPPS,1380,100,,,fee schedule,Pays 100% Medicare OPPS,1380,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,1124.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,4968,90,,,percent of total billed charges,90% of total billed charges,1932,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3792.24,68.7,,,percent of total billed charges,68.7% of total billed charges,4416,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,4968,90,,,fee schedule,Pays 90% Medicare OPPS,3201.6,58,,,percent of total billed charges,58% of total billed charges,1124.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4692,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1124.42,4968,
COLONOSCOPY CONTROL BLEED,1703028,CDM,750,RC,,,Outpatient,,,5520,4416,,4692,85,,,percent of total billed charges,85% of total billed charges,1380,100,,,fee schedule,Pays 100% Medicare OPPS,1380,100,,,fee schedule,Pays 100% Medicare OPPS,1380,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,1124.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,4968,90,,,percent of total billed charges,90% of total billed charges,1932,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3792.24,68.7,,,percent of total billed charges,68.7% of total billed charges,4416,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,4968,90,,,fee schedule,Pays 90% Medicare OPPS,3201.6,58,,,percent of total billed charges,58% of total billed charges,1124.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4692,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1124.42,4968,
"BIOPSY OF LIVER,NEEDLE; PERCUTANEOUS",1704700,CDM,750,RC,,,Outpatient,,,5520,4416,,4692,85,,,percent of total billed charges,85% of total billed charges,1380,100,,,fee schedule,Pays 100% Medicare OPPS,1380,100,,,fee schedule,Pays 100% Medicare OPPS,1380,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,1124.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,4968,90,,,percent of total billed charges,90% of total billed charges,1932,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3792.24,68.7,,,percent of total billed charges,68.7% of total billed charges,4416,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,4968,90,,,fee schedule,Pays 90% Medicare OPPS,3201.6,58,,,percent of total billed charges,58% of total billed charges,1124.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4692,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1124.42,4968,
......MRI HEAD W CONTRAST(BRAIN),4400005,CDM,611,RC,70552,HCPCS,Outpatient,,,5520,4416,,4692,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1124.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3118.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3118.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3118.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3102.24,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,4968,90,,,percent of total billed charges,90% of total billed charges,1932,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3792.24,68.7,,,percent of total billed charges,68.7% of total billed charges,4416,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,3201.6,58,,,percent of total billed charges,58% of total billed charges,1124.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,4692,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,4968,
MRI NECK WITH,4400006,CDM,611,RC,70542,HCPCS,Outpatient,,,5520,4416,,4692,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1124.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3118.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3118.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3118.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3102.24,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,4968,90,,,percent of total billed charges,90% of total billed charges,1932,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3792.24,68.7,,,percent of total billed charges,68.7% of total billed charges,4416,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,3201.6,58,,,percent of total billed charges,58% of total billed charges,1124.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,4692,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,4968,
MRI ORBITS WITH,4400007,CDM,611,RC,70542,HCPCS,Outpatient,,,5520,4416,,4692,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1124.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3118.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3118.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3118.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3102.24,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,4968,90,,,percent of total billed charges,90% of total billed charges,1932,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3792.24,68.7,,,percent of total billed charges,68.7% of total billed charges,4416,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,3201.6,58,,,percent of total billed charges,58% of total billed charges,1124.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,4692,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,4968,
MRI FACIAL ORBITS FACE WITH,4470542,CDM,611,RC,70542,HCPCS,Outpatient,,,5520,4416,,4692,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1124.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3118.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3118.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3118.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3102.24,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,4968,90,,,percent of total billed charges,90% of total billed charges,1932,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3792.24,68.7,,,percent of total billed charges,68.7% of total billed charges,4416,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,3201.6,58,,,percent of total billed charges,58% of total billed charges,1124.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,4692,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,4968,
......MRA HEAD W/CONTRAST,4470545,CDM,610,RC,70545,HCPCS,Outpatient,,,5520,4416,,4692,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1124.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3118.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3118.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3118.8,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3102.24,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,4968,90,,,percent of total billed charges,90% of total billed charges,1932,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3792.24,68.7,,,percent of total billed charges,68.7% of total billed charges,4416,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,3201.6,58,,,percent of total billed charges,58% of total billed charges,1124.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,4692,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,4968,
COLONOSCOPY W/BIOPSY,1703002,CDM,750,RC,,,Outpatient,,,5565,4452,,4730.25,85,,,percent of total billed charges,85% of total billed charges,1391.25,100,,,fee schedule,Pays 100% Medicare OPPS,1391.25,100,,,fee schedule,Pays 100% Medicare OPPS,1391.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,1133.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,5008.5,90,,,percent of total billed charges,90% of total billed charges,1947.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3823.16,68.7,,,percent of total billed charges,68.7% of total billed charges,4452,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,5008.5,90,,,fee schedule,Pays 90% Medicare OPPS,3227.7,58,,,percent of total billed charges,58% of total billed charges,1133.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4730.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1133.59,5008.5,
COLONOSCOPY W/POLYP REMOV,1703009,CDM,750,RC,,,Outpatient,,,5565,4452,,4730.25,85,,,percent of total billed charges,85% of total billed charges,1391.25,100,,,fee schedule,Pays 100% Medicare OPPS,1391.25,100,,,fee schedule,Pays 100% Medicare OPPS,1391.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,1133.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,5008.5,90,,,percent of total billed charges,90% of total billed charges,1947.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3823.16,68.7,,,percent of total billed charges,68.7% of total billed charges,4452,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,5008.5,90,,,fee schedule,Pays 90% Medicare OPPS,3227.7,58,,,percent of total billed charges,58% of total billed charges,1133.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4730.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1133.59,5008.5,
RECLAST (ZOLEDRONIC AC) INJ 5MG 100ML,2605009,CDM,636,RC,J3488,HCPCS,Both,,,5695,4556,,4840.75,85,,,percent of total billed charges,85% of total billed charges,1423.75,100,,,fee schedule,Pays 100% Medicare ,1423.75,100,,,fee schedule,Pays 100% Medicare ,1423.75,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,1160.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2971.14,52.17,,,case rate,100% of BCBS case rate,2971.14,52.17,,,case rate,100% of BCBS case rate,2971.14,52.17,,,case rate,100% of BCBS case rate,2971.14,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,5125.5,90,,,percent of total billed charges,90% of total billed charges,1993.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3912.47,68.7,,,percent of total billed charges,68.7% of total billed charges,4556,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,5125.5,90,,,fee schedule,Pays 90% Medicare ,3303.1,58,,,percent of total billed charges,58% of total billed charges,1160.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,4840.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1160.07,5125.5,
MRA BRAIN W/WO CONTRAST,4470546,CDM,610,RC,70546,HCPCS,Outpatient,,,5700,4560,,4845,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1161.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3220.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3220.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3220.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3203.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,5130,90,,,percent of total billed charges,90% of total billed charges,1995,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3915.9,68.7,,,percent of total billed charges,68.7% of total billed charges,4560,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,3306,58,,,percent of total billed charges,58% of total billed charges,1161.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,4845,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,5130,
MRA NECK W/WO CONTRAST,4470549,CDM,610,RC,70549,HCPCS,Outpatient,,,5700,4560,,4845,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1161.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3220.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3220.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3220.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3203.4,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,5130,90,,,percent of total billed charges,90% of total billed charges,1995,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3915.9,68.7,,,percent of total billed charges,68.7% of total billed charges,4560,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,3306,58,,,percent of total billed charges,58% of total billed charges,1161.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,4845,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,5130,
EXCISION TUMOR SOFT TISSUE < 3CM,1721555,CDM,761,RC,21555,HCPCS,Outpatient,,,5795,4636,,4925.75,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,1180.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,1289.21,102,,,fee schedule,Pays 102% Medicare OPPS,5215.5,90,,,percent of total billed charges,90% of total billed charges,2028.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3981.17,68.7,,,percent of total billed charges,68.7% of total billed charges,4636,80,,,percent of total billed charges,80 percent of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1137.55,90,,,fee schedule,Pays 90% Medicare OPPS,3361.1,58,,,percent of total billed charges,58% of total billed charges,1180.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1318.97,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare OPPS,4925.75,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1137.55,5215.5,
CL TREATMENT ARTICULAR FRACTURE,2026742,CDM,450,RC,26742,HCPCS,Outpatient,,,5795,4636,,4925.75,85,,,percent of total billed charges,85% of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1640.3,130,,,fee schedule,Pays 130% Medicare OPPS,1180.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,1276.23,102,,,fee schedule,Pays 102% Medicare OPPS,5215.5,90,,,percent of total billed charges,90% of total billed charges,2028.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,3981.17,68.7,,,percent of total billed charges,68.7% of total billed charges,4636,80,,,percent of total billed charges,80 percent of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1126.08,90,,,fee schedule,Pays 90% Medicare OPPS,3361.1,58,,,percent of total billed charges,58% of total billed charges,1180.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1261.77,100,,,fee schedule,Pays 100% Medicare OPPS,1640.3,130,,,fee schedule,Pays 130% Medicare OPPS,4925.75,85,,,percent of total billed charges,85% of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1126.08,5215.5,
Biopsies of large bowel using an endoscope which is inserted through abdominal opening,1544389,CDM,360,RC,44389,HCPCS,Outpatient,,,5940,4752,,5049,85,,,percent of total billed charges,85% of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,1238.25,130,,,fee schedule,Pays 130% Medicare ,1209.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,950.15,102,,,fee schedule,Pays 102% Medicare OPPS,5346,90,,,percent of total billed charges,90% of total billed charges,2079,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4080.78,68.7,,,percent of total billed charges,68.7% of total billed charges,4752,80,,,percent of total billed charges,80 percent of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,838.37,90,,,fee schedule,Pays 90% Medicare OPPS,3445.2,58,,,percent of total billed charges,58% of total billed charges,1209.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,952.5,100,,,fee schedule,Pays 100% Medicare OPPS,1238.25,130,,,fee schedule,Pays 130% Medicare ,5049,85,,,percent of total billed charges,85% of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,838.37,5346,
Removal of foreign bodies in large bowel using an endoscope,1545379,CDM,360,RC,45379,HCPCS,Outpatient,,,5940,4752,,5049,85,,,percent of total billed charges,85% of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,1238.25,130,,,fee schedule,Pays 130% Medicare OPPS,1209.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,950.15,102,,,fee schedule,Pays 102% Medicare OPPS,5346,90,,,percent of total billed charges,90% of total billed charges,2079,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4080.78,68.7,,,percent of total billed charges,68.7% of total billed charges,4752,80,,,percent of total billed charges,80 percent of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,838.37,90,,,fee schedule,Pays 90% Medicare OPPS,3445.2,58,,,percent of total billed charges,58% of total billed charges,1209.98,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,952.5,100,,,fee schedule,Pays 100% Medicare OPPS,1238.25,130,,,fee schedule,Pays 130% Medicare OPPS,5049,85,,,percent of total billed charges,85% of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,838.37,5346,
APLIGRAF,1570050,CDM,636,RC,Q4101,HCPCS,Both,,,5965,4772,,5070.25,85,,,percent of total billed charges,85% of total billed charges,1491.25,100,,,fee schedule,Pays 100% Medicare ,1491.25,100,,,fee schedule,Pays 100% Medicare ,1491.25,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,1215.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3112,52.17,,,case rate,100% of BCBS case rate,3112,52.17,,,case rate,100% of BCBS case rate,3112,52.17,,,case rate,100% of BCBS case rate,3112,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,5368.5,90,,,percent of total billed charges,90% of total billed charges,2087.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4097.96,68.7,,,percent of total billed charges,68.7% of total billed charges,4772,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,5368.5,90,,,fee schedule,Pays 90% Medicare ,3459.7,58,,,percent of total billed charges,58% of total billed charges,1215.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,5070.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1215.07,5368.5,
MRI of neck/spine with and without dye,4400008,CDM,612,RC,72156,HCPCS,Outpatient,,,5965,4772,,5070.25,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1215.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3370.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3370.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3370.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3352.33,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,5368.5,90,,,percent of total billed charges,90% of total billed charges,2087.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4097.96,68.7,,,percent of total billed charges,68.7% of total billed charges,4772,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,3459.7,58,,,percent of total billed charges,58% of total billed charges,1215.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,5070.25,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,5368.5,
MRI scan of brain before and after contrast,4400011,CDM,611,RC,70553,HCPCS,Outpatient,,,5965,4772,,5070.25,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1215.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3370.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3370.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3370.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3352.33,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,5368.5,90,,,percent of total billed charges,90% of total billed charges,2087.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4097.96,68.7,,,percent of total billed charges,68.7% of total billed charges,4772,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,3459.7,58,,,percent of total billed charges,58% of total billed charges,1215.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,5070.25,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,5368.5,
"MRI ORBITS, FACE, AND/OR NECK W/WO",4470543,CDM,610,RC,70543,HCPCS,Outpatient,,,5965,4772,,5070.25,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1215.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3370.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3370.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3370.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3352.33,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,5368.5,90,,,percent of total billed charges,90% of total billed charges,2087.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4097.96,68.7,,,percent of total billed charges,68.7% of total billed charges,4772,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,3459.7,58,,,percent of total billed charges,58% of total billed charges,1215.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,5070.25,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,5368.5,
MRI scan of brain before and after contrast,4470553,CDM,611,RC,70553,HCPCS,Outpatient,,,5965,4772,,5070.25,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1215.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3370.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3370.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3370.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3352.33,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,5368.5,90,,,percent of total billed charges,90% of total billed charges,2087.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4097.96,68.7,,,percent of total billed charges,68.7% of total billed charges,4772,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,3459.7,58,,,percent of total billed charges,58% of total billed charges,1215.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,5070.25,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,5368.5,
MRI of neck/spine with and without dye,4472156,CDM,612,RC,72156,HCPCS,Outpatient,,,5965,4772,,5070.25,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1215.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3370.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3370.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3370.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3352.33,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,5368.5,90,,,percent of total billed charges,90% of total billed charges,2087.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4097.96,68.7,,,percent of total billed charges,68.7% of total billed charges,4772,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,3459.7,58,,,percent of total billed charges,58% of total billed charges,1215.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,5070.25,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,5368.5,
MRI of lower back with and without dye,4472158,CDM,612,RC,72158,HCPCS,Outpatient,,,5965,4772,,5070.25,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1215.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3370.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3370.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3370.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3352.33,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,5368.5,90,,,percent of total billed charges,90% of total billed charges,2087.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4097.96,68.7,,,percent of total billed charges,68.7% of total billed charges,4772,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,3459.7,58,,,percent of total billed charges,58% of total billed charges,1215.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,5070.25,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,5368.5,
MRI of pelvis before and after dye,4472197,CDM,610,RC,72197,HCPCS,Outpatient,,,5965,4772,,5070.25,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare ,1215.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3370.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3370.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3370.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3352.33,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,5368.5,90,,,percent of total billed charges,90% of total billed charges,2087.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4097.96,68.7,,,percent of total billed charges,68.7% of total billed charges,4772,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,3459.7,58,,,percent of total billed charges,58% of total billed charges,1215.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare ,5070.25,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,5368.5,
MRI of abdomen without and with dye,4474183,CDM,610,RC,74183,HCPCS,Outpatient,,,5965,4772,,5070.25,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1215.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3370.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3370.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3370.23,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3352.33,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,5368.5,90,,,percent of total billed charges,90% of total billed charges,2087.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4097.96,68.7,,,percent of total billed charges,68.7% of total billed charges,4772,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,3459.7,58,,,percent of total billed charges,58% of total billed charges,1215.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,5070.25,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,5368.5,
HERNIA SURGIMESH XB,1570048,CDM,278,RC,C1781,HCPCS,Both,,,6020,4816,,5117,85,,,percent of total billed charges,85% of total billed charges,1505,100,,,fee schedule,Pays 100% Medicare ,1505,100,,,fee schedule,Pays 100% Medicare ,1505,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,1226.27,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3140.69,52.17,,,case rate,100% of BCBS case rate,3140.69,52.17,,,case rate,100% of BCBS case rate,3140.69,52.17,,,case rate,100% of BCBS case rate,3140.69,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,5418,90,,,percent of total billed charges,90% of total billed charges,2107,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4135.74,68.7,,,percent of total billed charges,68.7% of total billed charges,4816,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,5418,90,,,fee schedule,Pays 90% Medicare ,3491.6,58,,,percent of total billed charges,58% of total billed charges,1226.27,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,5117,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1226.27,5418,
.........MRA HEAD W/WO CONTRAST,4400004,CDM,610,RC,70546,HCPCS,Outpatient,,,6065,4852,,5155.25,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1235.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3426.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3426.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3426.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3408.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,5458.5,90,,,percent of total billed charges,90% of total billed charges,2122.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4166.66,68.7,,,percent of total billed charges,68.7% of total billed charges,4852,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,3517.7,58,,,percent of total billed charges,58% of total billed charges,1235.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,5155.25,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,5458.5,
MRA LOWER EXT W/O & W/CONTRAST,4408914,CDM,610,RC,73725,HCPCS,Outpatient,,,6065,4852,,5155.25,85,,,percent of total billed charges,85% of total billed charges,1516.25,100,,,fee schedule,Pays 100% Medicare OPPS,1516.25,100,,,fee schedule,Pays 100% Medicare OPPS,1516.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,1235.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3426.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3426.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3426.73,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3408.53,56.5,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,5458.5,90,,,percent of total billed charges,90% of total billed charges,2122.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4166.66,68.7,,,percent of total billed charges,68.7% of total billed charges,4852,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,5458.5,90,,,fee schedule,Pays 90% Medicare OPPS,3517.7,58,,,percent of total billed charges,58% of total billed charges,1235.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,5155.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1235.44,5458.5,
ESOPHAGOSCOPY WITH BALLOON <30MM,1743220,CDM,750,RC,43220,HCPCS,Outpatient,,,6240,4992,,5304,85,,,percent of total billed charges,85% of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1991.42,130,,,fee schedule,Pays 130% Medicare OPPS,1271.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,1488.23,102,,,fee schedule,Pays 102% Medicare OPPS,5616,90,,,percent of total billed charges,90% of total billed charges,2184,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4286.88,68.7,,,percent of total billed charges,68.7% of total billed charges,4992,80,,,percent of total billed charges,80 percent of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1313.14,90,,,fee schedule,Pays 90% Medicare OPPS,3619.2,58,,,percent of total billed charges,58% of total billed charges,1271.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1531.86,100,,,fee schedule,Pays 100% Medicare OPPS,1991.42,130,,,fee schedule,Pays 130% Medicare OPPS,5304,85,,,percent of total billed charges,85% of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,5616,
EGD INJECTION VARICES,1743243,CDM,750,RC,43243,HCPCS,Outpatient,,,6240,4992,,5304,85,,,percent of total billed charges,85% of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1991.42,130,,,fee schedule,Pays 130% Medicare OPPS,1271.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,1488.23,102,,,fee schedule,Pays 102% Medicare OPPS,5616,90,,,percent of total billed charges,90% of total billed charges,2184,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4286.88,68.7,,,percent of total billed charges,68.7% of total billed charges,4992,80,,,percent of total billed charges,80 percent of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1313.14,90,,,fee schedule,Pays 90% Medicare OPPS,3619.2,58,,,percent of total billed charges,58% of total billed charges,1271.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1531.86,100,,,fee schedule,Pays 100% Medicare OPPS,1991.42,130,,,fee schedule,Pays 130% Medicare OPPS,5304,85,,,percent of total billed charges,85% of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,5616,
EGD W/BAND LIGATION AND/OR GASTRIC VARI,1743244,CDM,750,RC,43244,HCPCS,Outpatient,,,6240,4992,,5304,85,,,percent of total billed charges,85% of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1991.42,130,,,fee schedule,Pays 130% Medicare OPPS,1271.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,1488.23,102,,,fee schedule,Pays 102% Medicare OPPS,5616,90,,,percent of total billed charges,90% of total billed charges,2184,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4286.88,68.7,,,percent of total billed charges,68.7% of total billed charges,4992,80,,,percent of total billed charges,80 percent of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1313.14,90,,,fee schedule,Pays 90% Medicare OPPS,3619.2,58,,,percent of total billed charges,58% of total billed charges,1271.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1531.86,100,,,fee schedule,Pays 100% Medicare OPPS,1991.42,130,,,fee schedule,Pays 130% Medicare OPPS,5304,85,,,percent of total billed charges,85% of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,5616,
EGD DILATE STRICTURE,1743245,CDM,750,RC,43245,HCPCS,Outpatient,,,6240,4992,,5304,85,,,percent of total billed charges,85% of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1991.42,130,,,fee schedule,Pays 130% Medicare OPPS,1271.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,1488.23,102,,,fee schedule,Pays 102% Medicare OPPS,5616,90,,,percent of total billed charges,90% of total billed charges,2184,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4286.88,68.7,,,percent of total billed charges,68.7% of total billed charges,4992,80,,,percent of total billed charges,80 percent of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1313.14,90,,,fee schedule,Pays 90% Medicare OPPS,3619.2,58,,,percent of total billed charges,58% of total billed charges,1271.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1531.86,100,,,fee schedule,Pays 100% Medicare OPPS,1991.42,130,,,fee schedule,Pays 130% Medicare OPPS,5304,85,,,percent of total billed charges,85% of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,5616,
EGD WITH LESION ABLATION,1743270,CDM,750,RC,43270,HCPCS,Outpatient,,,6240,4992,,5304,85,,,percent of total billed charges,85% of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1991.42,130,,,fee schedule,Pays 130% Medicare OPPS,1271.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,1488.23,102,,,fee schedule,Pays 102% Medicare OPPS,5616,90,,,percent of total billed charges,90% of total billed charges,2184,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4286.88,68.7,,,percent of total billed charges,68.7% of total billed charges,4992,80,,,percent of total billed charges,80 percent of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1313.14,90,,,fee schedule,Pays 90% Medicare OPPS,3619.2,58,,,percent of total billed charges,58% of total billed charges,1271.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1531.86,100,,,fee schedule,Pays 100% Medicare OPPS,1991.42,130,,,fee schedule,Pays 130% Medicare OPPS,5304,85,,,percent of total billed charges,85% of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,5616,
CT of abdomen and pelvis without dye,4274176,CDM,352,RC,74176,HCPCS,Outpatient,,,6445,5156,,5478.25,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,1312.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3641.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3641.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3641.43,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3622.09,56.5,,,percent of total billed charges,56.5 percent of total billed charges,210.83,102,,,fee schedule,Pays 102% Medicare OPPS,5800.5,90,,,percent of total billed charges,90% of total billed charges,2255.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4427.72,68.7,,,percent of total billed charges,68.7% of total billed charges,5156,80,,,percent of total billed charges,80 percent of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,90,,,fee schedule,Pays 90% Medicare OPPS,3738.1,58,,,percent of total billed charges,58% of total billed charges,1312.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,205.39,100,,,fee schedule,Pays 100% Medicare OPPS,267.01,130,,,fee schedule,Pays 130% Medicare OPPS,5478.25,85,,,percent of total billed charges,85% of total billed charges,206.7,100,,,fee schedule,Pays 100% Medicare OPPS,186.03,5800.5,
CT scan of abdomen and pelvis with contrast,4274177,CDM,352,RC,74177,HCPCS,Outpatient,,,6500,5200,,5525,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1324.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3672.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3672.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3672.5,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3653,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,5850,90,,,percent of total billed charges,90% of total billed charges,2275,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4465.5,68.7,,,percent of total billed charges,68.7% of total billed charges,5200,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,3770,58,,,percent of total billed charges,58% of total billed charges,1324.05,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,5525,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,5850,
SMALL BOWEL ENDOSCOPY,1744360,CDM,750,RC,44360,HCPCS,Outpatient,,,6565,5252,,5580.25,85,,,percent of total billed charges,85% of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1991.42,130,,,fee schedule,Pays 130% Medicare ,1337.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,1488.23,102,,,fee schedule,Pays 102% Medicare OPPS,5908.5,90,,,percent of total billed charges,90% of total billed charges,2297.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4510.16,68.7,,,percent of total billed charges,68.7% of total billed charges,5252,80,,,percent of total billed charges,80 percent of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1313.14,90,,,fee schedule,Pays 90% Medicare OPPS,3807.7,58,,,percent of total billed charges,58% of total billed charges,1337.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1531.86,100,,,fee schedule,Pays 100% Medicare OPPS,1991.42,130,,,fee schedule,Pays 130% Medicare ,5580.25,85,,,percent of total billed charges,85% of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,5908.5,
CLOSED TX OF ANKLE DISLOCATION W ANETH,2027842,CDM,450,RC,27842,HCPCS,Outpatient,,,6620,5296,,5627,85,,,percent of total billed charges,85% of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1640.3,130,,,fee schedule,Pays 130% Medicare ,1348.49,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,1276.23,102,,,fee schedule,Pays 102% Medicare OPPS,5958,90,,,percent of total billed charges,90% of total billed charges,2317,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4547.94,68.7,,,percent of total billed charges,68.7% of total billed charges,5296,80,,,percent of total billed charges,80 percent of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1126.08,90,,,fee schedule,Pays 90% Medicare OPPS,3839.6,58,,,percent of total billed charges,58% of total billed charges,1348.49,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1261.77,100,,,fee schedule,Pays 100% Medicare OPPS,1640.3,130,,,fee schedule,Pays 130% Medicare ,5627,85,,,percent of total billed charges,85% of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1126.08,5958,
IMPLANT HAMMERTOE KIT,1570028,CDM,278,RC,C1776,HCPCS,Both,,,6725,5380,,5716.25,85,,,percent of total billed charges,85% of total billed charges,1681.25,100,,,fee schedule,Pays 100% Medicare ,1681.25,100,,,fee schedule,Pays 100% Medicare ,1681.25,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,1369.88,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3508.5,52.17,,,case rate,100% of BCBS case rate,3508.5,52.17,,,case rate,100% of BCBS case rate,3508.5,52.17,,,case rate,100% of BCBS case rate,3508.5,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,6052.5,90,,,percent of total billed charges,90% of total billed charges,2353.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4620.08,68.7,,,percent of total billed charges,68.7% of total billed charges,5380,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,6052.5,90,,,fee schedule,Pays 90% Medicare ,3900.5,58,,,percent of total billed charges,58% of total billed charges,1369.88,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,5716.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1369.88,6052.5,
EXPANDERS BREAST TISSUE SDC140H 600CC,1570811,CDM,278,RC,,,Both,,,6732,5385.6,,5722.2,85,,,percent of total billed charges,85% of total billed charges,1683,100,,,fee schedule,Pays 100% Medicare ,1683,100,,,fee schedule,Pays 100% Medicare ,1683,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,1371.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3512.15,52.17,,,case rate,100% of BCBS case rate,3512.15,52.17,,,case rate,100% of BCBS case rate,3512.15,52.17,,,case rate,100% of BCBS case rate,3512.15,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,6058.8,90,,,percent of total billed charges,90% of total billed charges,2356.2,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4624.88,68.7,,,percent of total billed charges,68.7% of total billed charges,5385.6,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,6058.8,90,,,fee schedule,Pays 90% Medicare ,3904.56,58,,,percent of total billed charges,58% of total billed charges,1371.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,5722.2,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1371.31,6058.8,
HERNIA MESH PHASIX ST 1200710,1570388,CDM,278,RC,C1781,HCPCS,Both,,,6745,5396,,5733.25,85,,,percent of total billed charges,85% of total billed charges,1686.25,100,,,fee schedule,Pays 100% Medicare ,1686.25,100,,,fee schedule,Pays 100% Medicare ,1686.25,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,1373.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3518.93,52.17,,,case rate,100% of BCBS case rate,3518.93,52.17,,,case rate,100% of BCBS case rate,3518.93,52.17,,,case rate,100% of BCBS case rate,3518.93,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,6070.5,90,,,percent of total billed charges,90% of total billed charges,2360.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4633.82,68.7,,,percent of total billed charges,68.7% of total billed charges,5396,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,6070.5,90,,,fee schedule,Pays 90% Medicare ,3912.1,58,,,percent of total billed charges,58% of total billed charges,1373.96,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,5733.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1373.96,6070.5,
CROFAB (ANTIVENIN CROTALIDAE) INJ,2605136,CDM,636,RC,,,Both,,,6775,5420,,5758.75,85,,,percent of total billed charges,85% of total billed charges,1693.75,100,,,fee schedule,Pays 100% Medicare ,1693.75,100,,,fee schedule,Pays 100% Medicare ,1693.75,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,1380.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3534.59,52.17,,,case rate,100% of BCBS case rate,3534.59,52.17,,,case rate,100% of BCBS case rate,3534.59,52.17,,,case rate,100% of BCBS case rate,3534.59,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,6097.5,90,,,percent of total billed charges,90% of total billed charges,2371.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4654.43,68.7,,,percent of total billed charges,68.7% of total billed charges,5420,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,6097.5,90,,,fee schedule,Pays 90% Medicare ,3929.5,58,,,percent of total billed charges,58% of total billed charges,1380.07,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,5758.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1380.07,6097.5,
MRI UPPER EXT W/WO LEFT JNT,4400014,CDM,610,RC,73223,HCPCS,Outpatient,,,6820,5456,,5797,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1389.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3853.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3853.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3853.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3832.84,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,6138,90,,,percent of total billed charges,90% of total billed charges,2387,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4685.34,68.7,,,percent of total billed charges,68.7% of total billed charges,5456,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,3955.6,58,,,percent of total billed charges,58% of total billed charges,1389.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,5797,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,6138,
MRI of lower extremity joint (knee/ankle) with and without dye,4400022,CDM,610,RC,73723,HCPCS,Outpatient,,,6820,5456,,5797,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1389.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3853.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3853.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3853.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3832.84,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,6138,90,,,percent of total billed charges,90% of total billed charges,2387,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4685.34,68.7,,,percent of total billed charges,68.7% of total billed charges,5456,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,3955.6,58,,,percent of total billed charges,58% of total billed charges,1389.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,5797,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,6138,
MRI FACIAL ORBITS FACE W/WO,4470453,CDM,611,RC,70543,HCPCS,Outpatient,,,6820,5456,,5797,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1389.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3853.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3853.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3853.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3832.84,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,6138,90,,,percent of total billed charges,90% of total billed charges,2387,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4685.34,68.7,,,percent of total billed charges,68.7% of total billed charges,5456,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,3955.6,58,,,percent of total billed charges,58% of total billed charges,1389.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,5797,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,6138,
MRI UPPER RXT NON-JT W/WO,4473220,CDM,611,RC,73220,HCPCS,Outpatient,,,6820,5456,,5797,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1389.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3853.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3853.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3853.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3832.84,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,6138,90,,,percent of total billed charges,90% of total billed charges,2387,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4685.34,68.7,,,percent of total billed charges,68.7% of total billed charges,5456,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,3955.6,58,,,percent of total billed charges,58% of total billed charges,1389.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,5797,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,6138,
MRI UPPER EXT W/WO RIGHT JNT,4473223,CDM,610,RC,73223,HCPCS,Outpatient,,,6820,5456,,5797,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1389.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3853.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3853.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3853.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3832.84,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,6138,90,,,percent of total billed charges,90% of total billed charges,2387,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4685.34,68.7,,,percent of total billed charges,68.7% of total billed charges,5456,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,3955.6,58,,,percent of total billed charges,58% of total billed charges,1389.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,5797,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,6138,
MRI of lower extremity joint (knee/ankle) with and without dye,4473723,CDM,610,RC,73723,HCPCS,Outpatient,,,6820,5456,,5797,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1389.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3853.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3853.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3853.3,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3832.84,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,6138,90,,,percent of total billed charges,90% of total billed charges,2387,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4685.34,68.7,,,percent of total billed charges,68.7% of total billed charges,5456,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,3955.6,58,,,percent of total billed charges,58% of total billed charges,1389.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,5797,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,6138,
ENTEROSCOPY W BLEED CONTROL,1744366,CDM,750,RC,44366,HCPCS,Outpatient,,,6895,5516,,5860.75,85,,,percent of total billed charges,85% of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1991.42,130,,,fee schedule,Pays 130% Medicare OPPS,1404.51,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,1488.23,102,,,fee schedule,Pays 102% Medicare OPPS,6205.5,90,,,percent of total billed charges,90% of total billed charges,2413.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4736.87,68.7,,,percent of total billed charges,68.7% of total billed charges,5516,80,,,percent of total billed charges,80 percent of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1313.14,90,,,fee schedule,Pays 90% Medicare OPPS,3999.1,58,,,percent of total billed charges,58% of total billed charges,1404.51,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1531.86,100,,,fee schedule,Pays 100% Medicare OPPS,1991.42,130,,,fee schedule,Pays 130% Medicare OPPS,5860.75,85,,,percent of total billed charges,85% of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,6205.5,
SINUS BALLOON CATH 6MM SPIN RELIEVA,1570762,CDM,272,RC,,,Outpatient,,,6935,5548,,5894.75,85,,,percent of total billed charges,85% of total billed charges,1733.75,100,,,fee schedule,Pays 100% Medicare OPPS,1733.75,100,,,fee schedule,Pays 100% Medicare OPPS,1733.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,1412.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,6241.5,90,,,percent of total billed charges,90% of total billed charges,2427.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4764.35,68.7,,,percent of total billed charges,68.7% of total billed charges,5548,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,6241.5,90,,,fee schedule,Pays 90% Medicare OPPS,4022.3,58,,,percent of total billed charges,58% of total billed charges,1412.66,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,5894.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1412.66,6241.5,
CATH BARRX 90 RFA FOCAL,1750021,CDM,272,RC,,,Outpatient,,,7035,5628,,5979.75,85,,,percent of total billed charges,85% of total billed charges,1758.75,100,,,fee schedule,Pays 100% Medicare OPPS,1758.75,100,,,fee schedule,Pays 100% Medicare OPPS,1758.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,1433.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,6331.5,90,,,percent of total billed charges,90% of total billed charges,2462.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4833.05,68.7,,,percent of total billed charges,68.7% of total billed charges,5628,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,6331.5,90,,,fee schedule,Pays 90% Medicare OPPS,4080.3,58,,,percent of total billed charges,58% of total billed charges,1433.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,5979.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1433.03,6331.5,
COLPORRHAPHY,2057200,CDM,450,RC,57200,HCPCS,Outpatient,,,7035,5628,,5979.75,85,,,percent of total billed charges,85% of total billed charges,2356.88,100,,,fee schedule,Pays 100% Medicare OPPS,2356.88,100,,,fee schedule,Pays 100% Medicare OPPS,2356.88,100,,,fee schedule,Pays 100% Medicare OPPS,3233.04,130,,,fee schedule,Pays 130% Medicare OPPS,1433.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2404.02,102,,,fee schedule,Pays 102% Medicare OPPS,6331.5,90,,,percent of total billed charges,90% of total billed charges,2462.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4833.05,68.7,,,percent of total billed charges,68.7% of total billed charges,5628,80,,,percent of total billed charges,80 percent of total billed charges,2356.88,100,,,fee schedule,Pays 100% Medicare OPPS,2121.19,90,,,fee schedule,Pays 90% Medicare OPPS,4080.3,58,,,percent of total billed charges,58% of total billed charges,1433.03,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2486.96,100,,,fee schedule,Pays 100% Medicare OPPS,3233.04,130,,,fee schedule,Pays 130% Medicare OPPS,5979.75,85,,,percent of total billed charges,85% of total billed charges,2356.88,100,,,fee schedule,Pays 100% Medicare OPPS,1433.03,6331.5,
"Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections ",4274178,CDM,352,RC,74178,HCPCS,Outpatient,,,7090,5672,,6026.5,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,1444.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4005.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4005.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,4005.85,56.5,,,percent of total billed charges,56.5 percent of total billed charges,3984.58,56.5,,,percent of total billed charges,56.5 percent of total billed charges,337.41,102,,,fee schedule,Pays 102% Medicare OPPS,6381,90,,,percent of total billed charges,90% of total billed charges,2481.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4870.83,68.7,,,percent of total billed charges,68.7% of total billed charges,5672,80,,,percent of total billed charges,80 percent of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,90,,,fee schedule,Pays 90% Medicare OPPS,4112.2,58,,,percent of total billed charges,58% of total billed charges,1444.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,324.06,100,,,fee schedule,Pays 100% Medicare OPPS,421.27,130,,,fee schedule,Pays 130% Medicare OPPS,6026.5,85,,,percent of total billed charges,85% of total billed charges,330.8,100,,,fee schedule,Pays 100% Medicare OPPS,297.72,6381,
EXTENSOR TENDON REPAIR,2026418,CDM,450,RC,26418,HCPCS,Outpatient,,,7160,5728,,6086,85,,,percent of total billed charges,85% of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1640.3,130,,,fee schedule,Pays 130% Medicare ,1458.49,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,1276.23,102,,,fee schedule,Pays 102% Medicare OPPS,6444,90,,,percent of total billed charges,90% of total billed charges,2506,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4918.92,68.7,,,percent of total billed charges,68.7% of total billed charges,5728,80,,,percent of total billed charges,80 percent of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1126.08,90,,,fee schedule,Pays 90% Medicare OPPS,4152.8,58,,,percent of total billed charges,58% of total billed charges,1458.49,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1261.77,100,,,fee schedule,Pays 100% Medicare OPPS,1640.3,130,,,fee schedule,Pays 130% Medicare ,6086,85,,,percent of total billed charges,85% of total billed charges,1251.21,100,,,fee schedule,Pays 100% Medicare OPPS,1126.08,6444,
DECOMPRESS PLANTAR DIGITAL NERVE,1564726,CDM,360,RC,64726,HCPCS,Outpatient,,,7220,5776,,6137,85,,,percent of total billed charges,85% of total billed charges,1577.36,100,,,fee schedule,Pays 100% Medicare OPPS,1577.36,100,,,fee schedule,Pays 100% Medicare OPPS,1577.36,100,,,fee schedule,Pays 100% Medicare OPPS,2055.37,130,,,fee schedule,Pays 130% Medicare OPPS,1470.71,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,1608.9,102,,,fee schedule,Pays 102% Medicare OPPS,6498,90,,,percent of total billed charges,90% of total billed charges,2527,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4960.14,68.7,,,percent of total billed charges,68.7% of total billed charges,5776,80,,,percent of total billed charges,80 percent of total billed charges,1577.36,100,,,fee schedule,Pays 100% Medicare OPPS,1419.61,90,,,fee schedule,Pays 90% Medicare OPPS,4187.6,58,,,percent of total billed charges,58% of total billed charges,1470.71,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1581.06,100,,,fee schedule,Pays 100% Medicare OPPS,2055.37,130,,,fee schedule,Pays 130% Medicare OPPS,6137,85,,,percent of total billed charges,85% of total billed charges,1577.36,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,6498,
IMPLANT LPT REGULAR GREAT TOE SZ 0,1570040,CDM,278,RC,,,Both,,,7275,5820,,6183.75,85,,,percent of total billed charges,85% of total billed charges,1818.75,100,,,fee schedule,Pays 100% Medicare ,1818.75,100,,,fee schedule,Pays 100% Medicare ,1818.75,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,1481.92,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3795.44,52.17,,,case rate,100% of BCBS case rate,3795.44,52.17,,,case rate,100% of BCBS case rate,3795.44,52.17,,,case rate,100% of BCBS case rate,3795.44,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,6547.5,90,,,percent of total billed charges,90% of total billed charges,2546.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,4997.93,68.7,,,percent of total billed charges,68.7% of total billed charges,5820,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,6547.5,90,,,fee schedule,Pays 90% Medicare ,4219.5,58,,,percent of total billed charges,58% of total billed charges,1481.92,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,6183.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1481.92,6547.5,
CATH BARRX CHANNEL RFA ENDOSCOPIC,1750046,CDM,272,RC,,,Outpatient,,,7390,5912,,6281.5,85,,,percent of total billed charges,85% of total billed charges,1847.5,100,,,fee schedule,Pays 100% Medicare OPPS,1847.5,100,,,fee schedule,Pays 100% Medicare OPPS,1847.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,1505.34,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,6651,90,,,percent of total billed charges,90% of total billed charges,2586.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,5076.93,68.7,,,percent of total billed charges,68.7% of total billed charges,5912,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,6651,90,,,fee schedule,Pays 90% Medicare OPPS,4286.2,58,,,percent of total billed charges,58% of total billed charges,1505.34,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,6281.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1505.34,6651,
REMOVAL OF HEMORRHOID CLOT,1746320,CDM,750,RC,46320,HCPCS,Outpatient,,,7445,5956,,6328.25,85,,,percent of total billed charges,85% of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,1238.25,130,,,fee schedule,Pays 130% Medicare OPPS,1516.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,950.15,102,,,fee schedule,Pays 102% Medicare OPPS,6700.5,90,,,percent of total billed charges,90% of total billed charges,2605.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,5114.72,68.7,,,percent of total billed charges,68.7% of total billed charges,5956,80,,,percent of total billed charges,80 percent of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,838.37,90,,,fee schedule,Pays 90% Medicare OPPS,4318.1,58,,,percent of total billed charges,58% of total billed charges,1516.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,952.5,100,,,fee schedule,Pays 100% Medicare OPPS,1238.25,130,,,fee schedule,Pays 130% Medicare OPPS,6328.25,85,,,percent of total billed charges,85% of total billed charges,931.52,100,,,fee schedule,Pays 100% Medicare OPPS,838.37,6700.5,
INSERT PICVAD CATH,1536571,CDM,761,RC,36571,HCPCS,Outpatient,,,7450,5960,,6332.5,85,,,percent of total billed charges,85% of total billed charges,2571.56,100,,,fee schedule,Pays 100% Medicare OPPS,2571.56,100,,,fee schedule,Pays 100% Medicare OPPS,2571.56,100,,,fee schedule,Pays 100% Medicare OPPS,3406.31,130,,,fee schedule,Pays 130% Medicare OPPS,1517.57,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2622.99,102,,,fee schedule,Pays 102% Medicare OPPS,6705,90,,,percent of total billed charges,90% of total billed charges,2607.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,5118.15,68.7,,,percent of total billed charges,68.7% of total billed charges,5960,80,,,percent of total billed charges,80 percent of total billed charges,2571.56,100,,,fee schedule,Pays 100% Medicare OPPS,2314.4,90,,,fee schedule,Pays 90% Medicare OPPS,4321,58,,,percent of total billed charges,58% of total billed charges,1517.57,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2620.23,100,,,fee schedule,Pays 100% Medicare OPPS,3406.31,130,,,fee schedule,Pays 130% Medicare OPPS,6332.5,85,,,percent of total billed charges,85% of total billed charges,2571.56,100,,,fee schedule,Pays 100% Medicare OPPS,1517.57,6705,
MASTOMY W/EXPLORATION/DRAINAGE ABSCESS,1519020,CDM,360,RC,19020,HCPCS,Outpatient,,,7500,6000,,6375,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare ,1527.75,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,1289.21,102,,,fee schedule,Pays 102% Medicare OPPS,6750,90,,,percent of total billed charges,90% of total billed charges,2625,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,5152.5,68.7,,,percent of total billed charges,68.7% of total billed charges,6000,80,,,percent of total billed charges,80 percent of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,1137.55,90,,,fee schedule,Pays 90% Medicare OPPS,4350,58,,,percent of total billed charges,58% of total billed charges,1527.75,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1318.97,100,,,fee schedule,Pays 100% Medicare OPPS,1714.66,130,,,fee schedule,Pays 130% Medicare ,6375,85,,,percent of total billed charges,85% of total billed charges,1263.94,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,6750,
CANTHOTOMY SEPARATE PROCEDURE,1567715,CDM,360,RC,67715,HCPCS,Outpatient,,,7720,6176,,6562,85,,,percent of total billed charges,85% of total billed charges,1797.59,100,,,fee schedule,Pays 100% Medicare OPPS,1797.59,100,,,fee schedule,Pays 100% Medicare OPPS,1797.59,100,,,fee schedule,Pays 100% Medicare OPPS,2417.5,130,,,fee schedule,Pays 130% Medicare ,1572.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,1833.54,102,,,fee schedule,Pays 102% Medicare OPPS,6948,90,,,percent of total billed charges,90% of total billed charges,2702,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,5303.64,68.7,,,percent of total billed charges,68.7% of total billed charges,6176,80,,,percent of total billed charges,80 percent of total billed charges,1797.59,100,,,fee schedule,Pays 100% Medicare OPPS,1617.83,90,,,fee schedule,Pays 90% Medicare OPPS,4477.6,58,,,percent of total billed charges,58% of total billed charges,1572.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1859.61,100,,,fee schedule,Pays 100% Medicare OPPS,2417.5,130,,,fee schedule,Pays 130% Medicare ,6562,85,,,percent of total billed charges,85% of total billed charges,1797.59,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,6948,
EXPANDERS BREAST TISSUE SDC120H 375CC,1570810,CDM,278,RC,,,Both,,,7900,6320,,6715,85,,,percent of total billed charges,85% of total billed charges,1975,100,,,fee schedule,Pays 100% Medicare ,1975,100,,,fee schedule,Pays 100% Medicare ,1975,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,1609.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4121.51,52.17,,,case rate,100% of BCBS case rate,4121.51,52.17,,,case rate,100% of BCBS case rate,4121.51,52.17,,,case rate,100% of BCBS case rate,4121.51,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,7110,90,,,percent of total billed charges,90% of total billed charges,2765,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,5427.3,68.7,,,percent of total billed charges,68.7% of total billed charges,6320,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,7110,90,,,fee schedule,Pays 90% Medicare ,4582,58,,,percent of total billed charges,58% of total billed charges,1609.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,6715,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1609.23,7110,
EXPANDERS BREAST TISSUE SDC130H 475CC,1570812,CDM,278,RC,,,Both,,,7900,6320,,6715,85,,,percent of total billed charges,85% of total billed charges,1975,100,,,fee schedule,Pays 100% Medicare ,1975,100,,,fee schedule,Pays 100% Medicare ,1975,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,1609.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4121.51,52.17,,,case rate,100% of BCBS case rate,4121.51,52.17,,,case rate,100% of BCBS case rate,4121.51,52.17,,,case rate,100% of BCBS case rate,4121.51,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,7110,90,,,percent of total billed charges,90% of total billed charges,2765,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,5427.3,68.7,,,percent of total billed charges,68.7% of total billed charges,6320,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,7110,90,,,fee schedule,Pays 90% Medicare ,4582,58,,,percent of total billed charges,58% of total billed charges,1609.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,6715,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1609.23,7110,
CATH BARRX ULTRA LONG RFA FOCAL,1750044,CDM,272,RC,,,Outpatient,,,7945,6356,,6753.25,85,,,percent of total billed charges,85% of total billed charges,1986.25,100,,,fee schedule,Pays 100% Medicare OPPS,1986.25,100,,,fee schedule,Pays 100% Medicare OPPS,1986.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,1618.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,7150.5,90,,,percent of total billed charges,90% of total billed charges,2780.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,5458.22,68.7,,,percent of total billed charges,68.7% of total billed charges,6356,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,7150.5,90,,,fee schedule,Pays 90% Medicare OPPS,4608.1,58,,,percent of total billed charges,58% of total billed charges,1618.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,6753.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1618.4,7150.5,
EXPANDERS BREAST TISSUE SMXP110RH,1570806,CDM,278,RC,,,Both,,,7970,6376,,6774.5,85,,,percent of total billed charges,85% of total billed charges,1992.5,100,,,fee schedule,Pays 100% Medicare ,1992.5,100,,,fee schedule,Pays 100% Medicare ,1992.5,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,1623.49,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4158.03,52.17,,,case rate,100% of BCBS case rate,4158.03,52.17,,,case rate,100% of BCBS case rate,4158.03,52.17,,,case rate,100% of BCBS case rate,4158.03,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,7173,90,,,percent of total billed charges,90% of total billed charges,2789.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,5475.39,68.7,,,percent of total billed charges,68.7% of total billed charges,6376,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,7173,90,,,fee schedule,Pays 90% Medicare ,4622.6,58,,,percent of total billed charges,58% of total billed charges,1623.49,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,6774.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1623.49,7173,
EXPANDERS BREAST TISSUE SMXP150RH,1570809,CDM,278,RC,,,Both,,,7970,6376,,6774.5,85,,,percent of total billed charges,85% of total billed charges,1992.5,100,,,fee schedule,Pays 100% Medicare ,1992.5,100,,,fee schedule,Pays 100% Medicare ,1992.5,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,1623.49,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4158.03,52.17,,,case rate,100% of BCBS case rate,4158.03,52.17,,,case rate,100% of BCBS case rate,4158.03,52.17,,,case rate,100% of BCBS case rate,4158.03,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,7173,90,,,percent of total billed charges,90% of total billed charges,2789.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,5475.39,68.7,,,percent of total billed charges,68.7% of total billed charges,6376,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,7173,90,,,fee schedule,Pays 90% Medicare ,4622.6,58,,,percent of total billed charges,58% of total billed charges,1623.49,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,6774.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1623.49,7173,
OR ACUITY LEVEL II 1ST HOUR,1501151,CDM,360,RC,,,Outpatient,,,7995,6396,,6795.75,85,,,percent of total billed charges,85% of total billed charges,1998.75,100,,,fee schedule,Pays 100% Medicare OPPS,1998.75,100,,,fee schedule,Pays 100% Medicare OPPS,1998.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,1628.58,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,7195.5,90,,,percent of total billed charges,90% of total billed charges,2798.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,5492.57,68.7,,,percent of total billed charges,68.7% of total billed charges,6396,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,7195.5,90,,,fee schedule,Pays 90% Medicare OPPS,4637.1,58,,,percent of total billed charges,58% of total billed charges,1628.58,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,6795.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1628.58,7195.5,
ATT F/C/C/M//G/H/F; 10.1-30SQCM,1514041,CDM,360,RC,14041,HCPCS,Outpatient,,,8125,6500,,6906.25,85,,,percent of total billed charges,85% of total billed charges,1538.61,100,,,fee schedule,Pays 100% Medicare OPPS,1538.61,100,,,fee schedule,Pays 100% Medicare OPPS,1538.61,100,,,fee schedule,Pays 100% Medicare OPPS,1973.43,130,,,fee schedule,Pays 130% Medicare OPPS,1655.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,1569.38,102,,,fee schedule,Pays 102% Medicare OPPS,7312.5,90,,,percent of total billed charges,90% of total billed charges,2843.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,5581.88,68.7,,,percent of total billed charges,68.7% of total billed charges,6500,80,,,percent of total billed charges,80 percent of total billed charges,1538.61,100,,,fee schedule,Pays 100% Medicare OPPS,1384.75,90,,,fee schedule,Pays 90% Medicare OPPS,4712.5,58,,,percent of total billed charges,58% of total billed charges,1655.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1518.03,100,,,fee schedule,Pays 100% Medicare OPPS,1973.43,130,,,fee schedule,Pays 130% Medicare OPPS,6906.25,85,,,percent of total billed charges,85% of total billed charges,1538.61,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,7312.5,
ATT E/N/E/L;D 10.1-30SQCM,1514061,CDM,360,RC,14061,HCPCS,Outpatient,,,8125,6500,,6906.25,85,,,percent of total billed charges,85% of total billed charges,1538.61,100,,,fee schedule,Pays 100% Medicare OPPS,1538.61,100,,,fee schedule,Pays 100% Medicare OPPS,1538.61,100,,,fee schedule,Pays 100% Medicare OPPS,1973.43,130,,,fee schedule,Pays 130% Medicare OPPS,1655.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,1569.38,102,,,fee schedule,Pays 102% Medicare OPPS,7312.5,90,,,percent of total billed charges,90% of total billed charges,2843.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,5581.88,68.7,,,percent of total billed charges,68.7% of total billed charges,6500,80,,,percent of total billed charges,80 percent of total billed charges,1538.61,100,,,fee schedule,Pays 100% Medicare OPPS,1384.75,90,,,fee schedule,Pays 90% Medicare OPPS,4712.5,58,,,percent of total billed charges,58% of total billed charges,1655.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1518.03,100,,,fee schedule,Pays 100% Medicare OPPS,1973.43,130,,,fee schedule,Pays 130% Medicare OPPS,6906.25,85,,,percent of total billed charges,85% of total billed charges,1538.61,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,7312.5,
EGD PLACE GASTROSTOMY TUBE,1543246,CDM,360,RC,43246,HCPCS,Outpatient,,,8125,6500,,6906.25,85,,,percent of total billed charges,85% of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1991.42,130,,,fee schedule,Pays 130% Medicare ,1655.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,1488.23,102,,,fee schedule,Pays 102% Medicare OPPS,7312.5,90,,,percent of total billed charges,90% of total billed charges,2843.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,5581.88,68.7,,,percent of total billed charges,68.7% of total billed charges,6500,80,,,percent of total billed charges,80 percent of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,1313.14,90,,,fee schedule,Pays 90% Medicare OPPS,4712.5,58,,,percent of total billed charges,58% of total billed charges,1655.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1531.86,100,,,fee schedule,Pays 100% Medicare OPPS,1991.42,130,,,fee schedule,Pays 130% Medicare ,6906.25,85,,,percent of total billed charges,85% of total billed charges,1459.05,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,7312.5,
LAPS MOBIL SPLENIC FL ADDON,1544213,CDM,360,RC,44213,HCPCS,Outpatient,,,8125,6500,,6906.25,85,,,percent of total billed charges,85% of total billed charges,8125,100,,,fee schedule,Pays 100% Medicare OPPS,8125,100,,,fee schedule,Pays 100% Medicare OPPS,8125,100,,,fee schedule,Pays 100% Medicare OPPS,8125,130,APC,,fee schedule,Pays 130% Medicare OPPS,1655.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,8125,102,,,fee schedule,Pays 102% Medicare OPPS,7312.5,90,,,percent of total billed charges,90% of total billed charges,2843.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,5581.88,68.7,,,percent of total billed charges,68.7% of total billed charges,6500,80,,,percent of total billed charges,80 percent of total billed charges,8125,100,,,fee schedule,Pays 100% Medicare OPPS,8125,90,,,fee schedule,Pays 90% Medicare OPPS,4712.5,58,,,percent of total billed charges,58% of total billed charges,1655.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,8125,100,,,fee schedule,Pays 100% Medicare OPPS,8125,130,APC,,fee schedule,Pays 130% Medicare OPPS,6906.25,85,,,percent of total billed charges,85% of total billed charges,8125,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,8125,
HERNIA ECHO 2 POSITIONING SYSTEM 5992025,1570383,CDM,278,RC,C1781,HCPCS,Both,,,8645,6916,,7348.25,85,,,percent of total billed charges,85% of total billed charges,2161.25,100,,,fee schedule,Pays 100% Medicare ,2161.25,100,,,fee schedule,Pays 100% Medicare ,2161.25,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,1760.99,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4510.18,52.17,,,case rate,100% of BCBS case rate,4510.18,52.17,,,case rate,100% of BCBS case rate,4510.18,52.17,,,case rate,100% of BCBS case rate,4510.18,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,7780.5,90,,,percent of total billed charges,90% of total billed charges,3025.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,5939.12,68.7,,,percent of total billed charges,68.7% of total billed charges,6916,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,7780.5,90,,,fee schedule,Pays 90% Medicare ,5014.1,58,,,percent of total billed charges,58% of total billed charges,1760.99,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,7348.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,1760.99,7780.5,
HEMORRHOIDECTOMY INT XTRNL,1546260,CDM,360,RC,46260,HCPCS,Outpatient,,,9250,7400,,7862.5,85,,,percent of total billed charges,85% of total billed charges,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,2938.07,130,,,fee schedule,Pays 130% Medicare OPPS,1884.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2238.46,102,,,fee schedule,Pays 102% Medicare OPPS,8325,90,,,percent of total billed charges,90% of total billed charges,3237.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6354.75,68.7,,,percent of total billed charges,68.7% of total billed charges,7400,80,,,percent of total billed charges,80 percent of total billed charges,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,1975.12,90,,,fee schedule,Pays 90% Medicare OPPS,5365,58,,,percent of total billed charges,58% of total billed charges,1884.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2260.04,100,,,fee schedule,Pays 100% Medicare OPPS,2938.07,130,,,fee schedule,Pays 130% Medicare OPPS,7862.5,85,,,percent of total billed charges,85% of total billed charges,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,8325,
DESTRUCTION OF ANAL LESION(S),1746910,CDM,360,RC,46910,HCPCS,Outpatient,,,9250,7400,,7862.5,85,,,percent of total billed charges,85% of total billed charges,1538.61,100,,,fee schedule,Pays 100% Medicare OPPS,1538.61,100,,,fee schedule,Pays 100% Medicare OPPS,1538.61,100,,,fee schedule,Pays 100% Medicare OPPS,1973.43,130,,,fee schedule,Pays 130% Medicare OPPS,1884.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,1569.38,102,,,fee schedule,Pays 102% Medicare OPPS,8325,90,,,percent of total billed charges,90% of total billed charges,3237.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6354.75,68.7,,,percent of total billed charges,68.7% of total billed charges,7400,80,,,percent of total billed charges,80 percent of total billed charges,1538.61,100,,,fee schedule,Pays 100% Medicare OPPS,1384.75,90,,,fee schedule,Pays 90% Medicare OPPS,5365,58,,,percent of total billed charges,58% of total billed charges,1884.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,1518.03,100,,,fee schedule,Pays 100% Medicare OPPS,1973.43,130,,,fee schedule,Pays 130% Medicare OPPS,7862.5,85,,,percent of total billed charges,85% of total billed charges,1538.61,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,8325,
COLECTOMY PARTIAL W/END COLOSTOMY CLSR,1544143,CDM,360,RC,44143,HCPCS,Outpatient,,,9375,7500,,7968.75,85,,,percent of total billed charges,85% of total billed charges,9375,100,,,fee schedule,Pays 100% Medicare OPPS,9375,100,,,fee schedule,Pays 100% Medicare OPPS,9375,100,,,fee schedule,Pays 100% Medicare OPPS,9375,130,APC,,fee schedule,Pays 130% Medicare OPPS,1909.69,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,9375,102,,,fee schedule,Pays 102% Medicare OPPS,8437.5,90,,,percent of total billed charges,90% of total billed charges,3281.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6440.63,68.7,,,percent of total billed charges,68.7% of total billed charges,7500,80,,,percent of total billed charges,80 percent of total billed charges,9375,100,,,fee schedule,Pays 100% Medicare OPPS,9375,90,,,fee schedule,Pays 90% Medicare OPPS,5437.5,58,,,percent of total billed charges,58% of total billed charges,1909.69,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,9375,100,,,fee schedule,Pays 100% Medicare OPPS,9375,130,APC,,fee schedule,Pays 130% Medicare OPPS,7968.75,85,,,percent of total billed charges,85% of total billed charges,9375,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,9375,
BIOPSY OF ANORECTAL WALL ANAL APPROACH,1745100,CDM,360,RC,45100,HCPCS,Outpatient,,,9515,7612,,8087.75,85,,,percent of total billed charges,85% of total billed charges,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,2938.07,130,,,fee schedule,Pays 130% Medicare OPPS,1938.21,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2238.46,102,,,fee schedule,Pays 102% Medicare OPPS,8563.5,90,,,percent of total billed charges,90% of total billed charges,3330.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6536.81,68.7,,,percent of total billed charges,68.7% of total billed charges,7612,80,,,percent of total billed charges,80 percent of total billed charges,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,1975.12,90,,,fee schedule,Pays 90% Medicare OPPS,5518.7,58,,,percent of total billed charges,58% of total billed charges,1938.21,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2260.04,100,,,fee schedule,Pays 100% Medicare OPPS,2938.07,130,,,fee schedule,Pays 130% Medicare OPPS,8087.75,85,,,percent of total billed charges,85% of total billed charges,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,8563.5,
DESTROY ANAL LESION SIMPLE,1746922,CDM,360,RC,46922,HCPCS,Outpatient,,,9515,7612,,8087.75,85,,,percent of total billed charges,85% of total billed charges,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,2938.07,130,,,fee schedule,Pays 130% Medicare OPPS,1938.21,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2238.46,102,,,fee schedule,Pays 102% Medicare OPPS,8563.5,90,,,percent of total billed charges,90% of total billed charges,3330.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6536.81,68.7,,,percent of total billed charges,68.7% of total billed charges,7612,80,,,percent of total billed charges,80 percent of total billed charges,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,1975.12,90,,,fee schedule,Pays 90% Medicare OPPS,5518.7,58,,,percent of total billed charges,58% of total billed charges,1938.21,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2260.04,100,,,fee schedule,Pays 100% Medicare OPPS,2938.07,130,,,fee schedule,Pays 130% Medicare OPPS,8087.75,85,,,percent of total billed charges,85% of total billed charges,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,8563.5,
ERCP W BX SINGLE/MULTIBLE,1743261,CDM,750,RC,43261,HCPCS,Outpatient,,,9845,7876,,8368.25,85,,,percent of total billed charges,85% of total billed charges,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,3728.44,130,,,fee schedule,Pays 130% Medicare OPPS,2005.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2813.43,102,,,fee schedule,Pays 102% Medicare OPPS,8860.5,90,,,percent of total billed charges,90% of total billed charges,3445.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6763.52,68.7,,,percent of total billed charges,68.7% of total billed charges,7876,80,,,percent of total billed charges,80 percent of total billed charges,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,2482.44,90,,,fee schedule,Pays 90% Medicare OPPS,5710.1,58,,,percent of total billed charges,58% of total billed charges,2005.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2868.03,100,,,fee schedule,Pays 100% Medicare OPPS,3728.44,130,,,fee schedule,Pays 130% Medicare OPPS,8368.25,85,,,percent of total billed charges,85% of total billed charges,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,8860.5,
ENDOSCOPIC PANCREATOSCOPY,1743273,CDM,750,RC,43273,HCPCS,Outpatient,,,9845,7876,,8368.25,85,,,percent of total billed charges,85% of total billed charges,2461.25,100,,,fee schedule,Pays 100% Medicare OPPS,2461.25,100,,,fee schedule,Pays 100% Medicare OPPS,2461.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2005.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,,,,,other,Not reimbursable per contract,8860.5,90,,,percent of total billed charges,90% of total billed charges,3445.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6763.52,68.7,,,percent of total billed charges,68.7% of total billed charges,7876,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,8860.5,90,,,fee schedule,Pays 90% Medicare OPPS,5710.1,58,,,percent of total billed charges,58% of total billed charges,2005.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8368.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,862.48,8860.5,
CATH BARRX RFA EXPRESS BALLOON,1750045,CDM,272,RC,,,Outpatient,,,9985,7988,,8487.25,85,,,percent of total billed charges,85% of total billed charges,2496.25,100,,,fee schedule,Pays 100% Medicare OPPS,2496.25,100,,,fee schedule,Pays 100% Medicare OPPS,2496.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2033.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,8986.5,90,,,percent of total billed charges,90% of total billed charges,3494.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6859.7,68.7,,,percent of total billed charges,68.7% of total billed charges,7988,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,8986.5,90,,,fee schedule,Pays 90% Medicare OPPS,5791.3,58,,,percent of total billed charges,58% of total billed charges,2033.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8487.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2000,8986.5,
STENT WALLFLEX FULLY COVER ESOPH 15.5CM,1750061,CDM,272,RC,,,Outpatient,,,10045,8036,,8538.25,85,,,percent of total billed charges,85% of total billed charges,2511.25,100,,,fee schedule,Pays 100% Medicare OPPS,2511.25,100,,,fee schedule,Pays 100% Medicare OPPS,2511.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2046.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9040.5,90,,,percent of total billed charges,90% of total billed charges,3515.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6900.92,68.7,,,percent of total billed charges,68.7% of total billed charges,8036,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9040.5,90,,,fee schedule,Pays 90% Medicare OPPS,5826.1,58,,,percent of total billed charges,58% of total billed charges,2046.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8538.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2000,9040.5,
STENT WALLFLEX FULLY COVER ESOPH 10.5CM,1750063,CDM,272,RC,,,Outpatient,,,10045,8036,,8538.25,85,,,percent of total billed charges,85% of total billed charges,2511.25,100,,,fee schedule,Pays 100% Medicare OPPS,2511.25,100,,,fee schedule,Pays 100% Medicare OPPS,2511.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2046.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9040.5,90,,,percent of total billed charges,90% of total billed charges,3515.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6900.92,68.7,,,percent of total billed charges,68.7% of total billed charges,8036,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9040.5,90,,,fee schedule,Pays 90% Medicare OPPS,5826.1,58,,,percent of total billed charges,58% of total billed charges,2046.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,8538.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2000,9040.5,
RESECT NECK TUMOR 5CM/>,1521558,CDM,360,RC,21558,HCPCS,Outpatient,,,10160,8128,,8636,85,,,percent of total billed charges,85% of total billed charges,2129.94,100,,,fee schedule,Pays 100% Medicare OPPS,2129.94,100,,,fee schedule,Pays 100% Medicare OPPS,2129.94,100,,,fee schedule,Pays 100% Medicare OPPS,2953.82,130,,,fee schedule,Pays 130% Medicare OPPS,2069.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2172.54,102,,,fee schedule,Pays 102% Medicare OPPS,9144,90,,,percent of total billed charges,90% of total billed charges,3556,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6979.92,68.7,,,percent of total billed charges,68.7% of total billed charges,8128,80,,,percent of total billed charges,80 percent of total billed charges,2129.94,100,,,fee schedule,Pays 100% Medicare OPPS,1916.94,90,,,fee schedule,Pays 90% Medicare OPPS,5892.8,58,,,percent of total billed charges,58% of total billed charges,2069.59,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2272.17,100,,,fee schedule,Pays 100% Medicare OPPS,2953.82,130,,,fee schedule,Pays 130% Medicare OPPS,8636,85,,,percent of total billed charges,85% of total billed charges,2129.94,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,9144,
ERCP W SPHINCTER PAPILLOTOMY,1743262,CDM,750,RC,43262,HCPCS,Outpatient,,,10175,8140,,8648.75,85,,,percent of total billed charges,85% of total billed charges,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,3728.44,130,,,fee schedule,Pays 130% Medicare OPPS,2072.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2813.43,102,,,fee schedule,Pays 102% Medicare OPPS,9157.5,90,,,percent of total billed charges,90% of total billed charges,3561.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6990.23,68.7,,,percent of total billed charges,68.7% of total billed charges,8140,80,,,percent of total billed charges,80 percent of total billed charges,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,2482.44,90,,,fee schedule,Pays 90% Medicare OPPS,5901.5,58,,,percent of total billed charges,58% of total billed charges,2072.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2868.03,100,,,fee schedule,Pays 100% Medicare OPPS,3728.44,130,,,fee schedule,Pays 130% Medicare OPPS,8648.75,85,,,percent of total billed charges,85% of total billed charges,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,9157.5,
ERCP REMOVE DUCT CALCULI,1743264,CDM,750,RC,43264,HCPCS,Outpatient,,,10175,8140,,8648.75,85,,,percent of total billed charges,85% of total billed charges,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,3728.44,130,,,fee schedule,Pays 130% Medicare OPPS,2072.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2813.43,102,,,fee schedule,Pays 102% Medicare OPPS,9157.5,90,,,percent of total billed charges,90% of total billed charges,3561.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6990.23,68.7,,,percent of total billed charges,68.7% of total billed charges,8140,80,,,percent of total billed charges,80 percent of total billed charges,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,2482.44,90,,,fee schedule,Pays 90% Medicare OPPS,5901.5,58,,,percent of total billed charges,58% of total billed charges,2072.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2868.03,100,,,fee schedule,Pays 100% Medicare OPPS,3728.44,130,,,fee schedule,Pays 130% Medicare OPPS,8648.75,85,,,percent of total billed charges,85% of total billed charges,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,9157.5,
ERCP EA DUCT/AMPULLA DILATE,1743277,CDM,750,RC,43277,HCPCS,Outpatient,,,10175,8140,,8648.75,85,,,percent of total billed charges,85% of total billed charges,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,3728.44,130,,,fee schedule,Pays 130% Medicare OPPS,2072.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2813.43,102,,,fee schedule,Pays 102% Medicare OPPS,9157.5,90,,,percent of total billed charges,90% of total billed charges,3561.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,6990.23,68.7,,,percent of total billed charges,68.7% of total billed charges,8140,80,,,percent of total billed charges,80 percent of total billed charges,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,2482.44,90,,,fee schedule,Pays 90% Medicare OPPS,5901.5,58,,,percent of total billed charges,58% of total billed charges,2072.65,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2868.03,100,,,fee schedule,Pays 100% Medicare OPPS,3728.44,130,,,fee schedule,Pays 130% Medicare OPPS,8648.75,85,,,percent of total billed charges,85% of total billed charges,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,9157.5,
REMOVE INT/EXT HEM 1 GROUP,1546255,CDM,360,RC,46255,HCPCS,Outpatient,,,10270,8216,,8729.5,85,,,percent of total billed charges,85% of total billed charges,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,2938.07,130,,,fee schedule,Pays 130% Medicare OPPS,2092,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2238.46,102,,,fee schedule,Pays 102% Medicare OPPS,9243,90,,,percent of total billed charges,90% of total billed charges,3594.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,7055.49,68.7,,,percent of total billed charges,68.7% of total billed charges,8216,80,,,percent of total billed charges,80 percent of total billed charges,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,1975.12,90,,,fee schedule,Pays 90% Medicare OPPS,5956.6,58,,,percent of total billed charges,58% of total billed charges,2092,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2260.04,100,,,fee schedule,Pays 100% Medicare OPPS,2938.07,130,,,fee schedule,Pays 130% Medicare OPPS,8729.5,85,,,percent of total billed charges,85% of total billed charges,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,9243,
HEMORRHOIDOPEXY BY STAPLING,1546947,CDM,360,RC,46947,HCPCS,Outpatient,,,10270,8216,,8729.5,85,,,percent of total billed charges,85% of total billed charges,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,2938.07,130,,,fee schedule,Pays 130% Medicare OPPS,2092,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2238.46,102,,,fee schedule,Pays 102% Medicare OPPS,9243,90,,,percent of total billed charges,90% of total billed charges,3594.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,7055.49,68.7,,,percent of total billed charges,68.7% of total billed charges,8216,80,,,percent of total billed charges,80 percent of total billed charges,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,1975.12,90,,,fee schedule,Pays 90% Medicare OPPS,5956.6,58,,,percent of total billed charges,58% of total billed charges,2092,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2260.04,100,,,fee schedule,Pays 100% Medicare OPPS,2938.07,130,,,fee schedule,Pays 130% Medicare OPPS,8729.5,85,,,percent of total billed charges,85% of total billed charges,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,9243,
EXCISION HIDRADENITIS INGUINAL SMPL/INTR,1511462,CDM,360,RC,11462,HCPCS,Outpatient,,,10315,8252,,8767.75,85,,,percent of total billed charges,85% of total billed charges,2129.94,100,,,fee schedule,Pays 100% Medicare OPPS,2129.94,100,,,fee schedule,Pays 100% Medicare OPPS,2129.94,100,,,fee schedule,Pays 100% Medicare OPPS,2953.82,130,,,fee schedule,Pays 130% Medicare OPPS,2101.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2172.54,102,,,fee schedule,Pays 102% Medicare OPPS,9283.5,90,,,percent of total billed charges,90% of total billed charges,3610.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,7086.41,68.7,,,percent of total billed charges,68.7% of total billed charges,8252,80,,,percent of total billed charges,80 percent of total billed charges,2129.94,100,,,fee schedule,Pays 100% Medicare OPPS,1916.94,90,,,fee schedule,Pays 90% Medicare OPPS,5982.7,58,,,percent of total billed charges,58% of total billed charges,2101.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2272.17,100,,,fee schedule,Pays 100% Medicare OPPS,2953.82,130,,,fee schedule,Pays 130% Medicare OPPS,8767.75,85,,,percent of total billed charges,85% of total billed charges,2129.94,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,9283.5,
EXC NECK LES SC 3 CM/>,1521552,CDM,360,RC,21552,HCPCS,Outpatient,,,10315,8252,,8767.75,85,,,percent of total billed charges,85% of total billed charges,2129.94,100,,,fee schedule,Pays 100% Medicare OPPS,2129.94,100,,,fee schedule,Pays 100% Medicare OPPS,2129.94,100,,,fee schedule,Pays 100% Medicare OPPS,2953.82,130,,,fee schedule,Pays 130% Medicare OPPS,2101.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2172.54,102,,,fee schedule,Pays 102% Medicare OPPS,9283.5,90,,,percent of total billed charges,90% of total billed charges,3610.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,7086.41,68.7,,,percent of total billed charges,68.7% of total billed charges,8252,80,,,percent of total billed charges,80 percent of total billed charges,2129.94,100,,,fee schedule,Pays 100% Medicare OPPS,1916.94,90,,,fee schedule,Pays 90% Medicare OPPS,5982.7,58,,,percent of total billed charges,58% of total billed charges,2101.17,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2272.17,100,,,fee schedule,Pays 100% Medicare OPPS,2953.82,130,,,fee schedule,Pays 130% Medicare OPPS,8767.75,85,,,percent of total billed charges,85% of total billed charges,2129.94,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,9283.5,
ESOPHAGOSCOPY LESION ABLATE,1743229,CDM,750,RC,43229,HCPCS,Outpatient,,,10340,8272,,8789,85,,,percent of total billed charges,85% of total billed charges,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,3728.44,130,,,fee schedule,Pays 130% Medicare OPPS,2106.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2813.43,102,,,fee schedule,Pays 102% Medicare OPPS,9306,90,,,percent of total billed charges,90% of total billed charges,3619,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,7103.58,68.7,,,percent of total billed charges,68.7% of total billed charges,8272,80,,,percent of total billed charges,80 percent of total billed charges,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,2482.44,90,,,fee schedule,Pays 90% Medicare OPPS,5997.2,58,,,percent of total billed charges,58% of total billed charges,2106.26,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2868.03,100,,,fee schedule,Pays 100% Medicare OPPS,3728.44,130,,,fee schedule,Pays 130% Medicare OPPS,8789,85,,,percent of total billed charges,85% of total billed charges,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,9306,
REMOVAL OF BREAST TISSUE,1519300,CDM,360,RC,19300,HCPCS,Outpatient,,,10500,8400,,8925,85,,,percent of total billed charges,85% of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,3930.96,130,,,fee schedule,Pays 130% Medicare OPPS,2138.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2893.37,102,,,fee schedule,Pays 102% Medicare OPPS,9450,90,,,percent of total billed charges,90% of total billed charges,3675,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,7213.5,68.7,,,percent of total billed charges,68.7% of total billed charges,8400,80,,,percent of total billed charges,80 percent of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2552.98,90,,,fee schedule,Pays 90% Medicare OPPS,6090,58,,,percent of total billed charges,58% of total billed charges,2138.85,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3023.82,100,,,fee schedule,Pays 100% Medicare OPPS,3930.96,130,,,fee schedule,Pays 130% Medicare OPPS,8925,85,,,percent of total billed charges,85% of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,9450,
Removal of large bowel tissue using an endoscope,1545390,CDM,360,RC,45390,HCPCS,Outpatient,,,10690,8552,,9086.5,85,,,percent of total billed charges,85% of total billed charges,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,2938.07,130,,,fee schedule,Pays 130% Medicare ,2177.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2238.46,102,,,fee schedule,Pays 102% Medicare OPPS,9621,90,,,percent of total billed charges,90% of total billed charges,3741.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,7344.03,68.7,,,percent of total billed charges,68.7% of total billed charges,8552,80,,,percent of total billed charges,80 percent of total billed charges,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,1975.12,90,,,fee schedule,Pays 90% Medicare OPPS,6200.2,58,,,percent of total billed charges,58% of total billed charges,2177.55,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2260.04,100,,,fee schedule,Pays 100% Medicare OPPS,2938.07,130,,,fee schedule,Pays 130% Medicare ,9086.5,85,,,percent of total billed charges,85% of total billed charges,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,9621,
INT HRHC LIG 2 HROID W/O IMG,1546946,CDM,360,RC,46946,HCPCS,Outpatient,,,10710,8568,,9103.5,85,,,percent of total billed charges,85% of total billed charges,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,2938.07,130,,,fee schedule,Pays 130% Medicare OPPS,2181.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2238.46,102,,,fee schedule,Pays 102% Medicare OPPS,9639,90,,,percent of total billed charges,90% of total billed charges,3748.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,7357.77,68.7,,,percent of total billed charges,68.7% of total billed charges,8568,80,,,percent of total billed charges,80 percent of total billed charges,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,1975.12,90,,,fee schedule,Pays 90% Medicare OPPS,6211.8,58,,,percent of total billed charges,58% of total billed charges,2181.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2260.04,100,,,fee schedule,Pays 100% Medicare OPPS,2938.07,130,,,fee schedule,Pays 130% Medicare OPPS,9103.5,85,,,percent of total billed charges,85% of total billed charges,2194.58,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,9639,
HERNIA ECHO 2 POSITIONING SYSTEM 5992533,1570386,CDM,278,RC,C1781,HCPCS,Both,,,10735,8588,,9124.75,85,,,percent of total billed charges,85% of total billed charges,2683.75,100,,,fee schedule,Pays 100% Medicare ,2683.75,100,,,fee schedule,Pays 100% Medicare ,2683.75,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,2186.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5600.56,52.17,,,case rate,100% of BCBS case rate,5600.56,52.17,,,case rate,100% of BCBS case rate,5600.56,52.17,,,case rate,100% of BCBS case rate,5600.56,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,9661.5,90,,,percent of total billed charges,90% of total billed charges,3757.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,7374.95,68.7,,,percent of total billed charges,68.7% of total billed charges,8588,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9661.5,90,,,fee schedule,Pays 90% Medicare ,6226.3,58,,,percent of total billed charges,58% of total billed charges,2186.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9124.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2186.72,9661.5,
ERCP W/SPECIMEN COLLECTION,1743260,CDM,750,RC,43260,HCPCS,Outpatient,,,10835,8668,,9209.75,85,,,percent of total billed charges,85% of total billed charges,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,3728.44,130,,,fee schedule,Pays 130% Medicare OPPS,2207.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2813.43,102,,,fee schedule,Pays 102% Medicare OPPS,9751.5,90,,,percent of total billed charges,90% of total billed charges,3792.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,7443.65,68.7,,,percent of total billed charges,68.7% of total billed charges,8668,80,,,percent of total billed charges,80 percent of total billed charges,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,2482.44,90,,,fee schedule,Pays 90% Medicare OPPS,6284.3,58,,,percent of total billed charges,58% of total billed charges,2207.09,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2868.03,100,,,fee schedule,Pays 100% Medicare OPPS,3728.44,130,,,fee schedule,Pays 130% Medicare OPPS,9209.75,85,,,percent of total billed charges,85% of total billed charges,2758.27,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,9751.5,
LUPRON DEPOT (LEUPROLIDE 3M) INJ: 22.5MG,2601277,CDM,636,RC,J1950,HCPCS,Both,,,10895,8716,,9260.75,85,,,percent of total billed charges,85% of total billed charges,1477.55,100,,,fee schedule,Pays 100% Medicare ,1477.55,100,,,fee schedule,Pays 100% Medicare ,1477.55,100,,,fee schedule,Pays 100% Medicare ,1981.64,130,,,fee schedule,Pays 130% Medicare OPPS,1778.53,120.37,,,fee schedule,120.37% of custom fee schedule,5684.03,52.17,,,case rate,100% of BCBS case rate,5684.03,52.17,,,case rate,100% of BCBS case rate,5684.03,52.17,,,case rate,100% of BCBS case rate,5684.03,52.17,,,case rate,100% of BCBS case rate,1507.1,102,,,fee schedule,Pays 102% Medicare ,9805.5,90,,,percent of total billed charges,90% of total billed charges,1849.6,125.18,,,fee schedule,125.18% of custom fee schedule,7484.87,68.7,,,percent of total billed charges,68.7% of total billed charges,8716,80,,,percent of total billed charges,80 percent of total billed charges,1477.55,100,,,fee schedule,Pays 100% Medicare ,1329.79,90,,,fee schedule,Pays 90% Medicare ,6319.1,58,,,percent of total billed charges,58% of total billed charges,1778.53,120.37,,,fee schedule,120.37% of custom fee schedule,1524.34,100,,,fee schedule,Pays 100% Medicare ,1981.64,130,,,fee schedule,Pays 130% Medicare OPPS,9260.75,85,,,percent of total billed charges,85% of total billed charges,1477.55,100,,,fee schedule,Pays 100% Medicare ,1329.79,9805.5,
SPYSCOPE DS ACCESS AND DELIVERY CATHETER,1750054,CDM,272,RC,,,Outpatient,,,10940,8752,,9299,85,,,percent of total billed charges,85% of total billed charges,2735,100,,,fee schedule,Pays 100% Medicare OPPS,2735,100,,,fee schedule,Pays 100% Medicare OPPS,2735,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2228.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,9846,90,,,percent of total billed charges,90% of total billed charges,3829,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,7515.78,68.7,,,percent of total billed charges,68.7% of total billed charges,8752,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,9846,90,,,fee schedule,Pays 90% Medicare OPPS,6345.2,58,,,percent of total billed charges,58% of total billed charges,2228.48,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9299,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2000,9846,
NIPPLE EXPLORATION,1519110,CDM,360,RC,19110,HCPCS,Outpatient,,,10975,8780,,9328.75,85,,,percent of total billed charges,85% of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,3930.96,130,,,fee schedule,Pays 130% Medicare OPPS,2235.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2893.37,102,,,fee schedule,Pays 102% Medicare OPPS,9877.5,90,,,percent of total billed charges,90% of total billed charges,3841.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,7539.83,68.7,,,percent of total billed charges,68.7% of total billed charges,8780,80,,,percent of total billed charges,80 percent of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2552.98,90,,,fee schedule,Pays 90% Medicare OPPS,6365.5,58,,,percent of total billed charges,58% of total billed charges,2235.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3023.82,100,,,fee schedule,Pays 100% Medicare OPPS,3930.96,130,,,fee schedule,Pays 130% Medicare OPPS,9328.75,85,,,percent of total billed charges,85% of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,9877.5,
EXC BREASTLES BY N LOC; SGL,1519125,CDM,360,RC,19125,HCPCS,Outpatient,,,10975,8780,,9328.75,85,,,percent of total billed charges,85% of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,3930.96,130,,,fee schedule,Pays 130% Medicare OPPS,2235.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2893.37,102,,,fee schedule,Pays 102% Medicare OPPS,9877.5,90,,,percent of total billed charges,90% of total billed charges,3841.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,7539.83,68.7,,,percent of total billed charges,68.7% of total billed charges,8780,80,,,percent of total billed charges,80 percent of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2552.98,90,,,fee schedule,Pays 90% Medicare OPPS,6365.5,58,,,percent of total billed charges,58% of total billed charges,2235.61,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3023.82,100,,,fee schedule,Pays 100% Medicare OPPS,3930.96,130,,,fee schedule,Pays 130% Medicare OPPS,9328.75,85,,,percent of total billed charges,85% of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,9877.5,
STENT WALLFLEX ENTERAL COLONIC 30/25 X 6,1750047,CDM,272,RC,,,Outpatient,,,11140,8912,,9469,85,,,percent of total billed charges,85% of total billed charges,2785,100,,,fee schedule,Pays 100% Medicare OPPS,2785,100,,,fee schedule,Pays 100% Medicare OPPS,2785,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2269.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,10026,90,,,percent of total billed charges,90% of total billed charges,3899,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,7653.18,68.7,,,percent of total billed charges,68.7% of total billed charges,8912,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,10026,90,,,fee schedule,Pays 90% Medicare OPPS,6461.2,58,,,percent of total billed charges,58% of total billed charges,2269.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9469,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2000,10026,
STENT WALLFLEX ENTERAL COLONIC 30/25 X 9,1750048,CDM,272,RC,,,Outpatient,,,11140,8912,,9469,85,,,percent of total billed charges,85% of total billed charges,2785,100,,,fee schedule,Pays 100% Medicare OPPS,2785,100,,,fee schedule,Pays 100% Medicare OPPS,2785,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2269.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,10026,90,,,percent of total billed charges,90% of total billed charges,3899,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,7653.18,68.7,,,percent of total billed charges,68.7% of total billed charges,8912,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,10026,90,,,fee schedule,Pays 90% Medicare OPPS,6461.2,58,,,percent of total billed charges,58% of total billed charges,2269.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9469,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2000,10026,
STENT WALLFLEX ENTERAL COLONIC 30/25 X1,1750049,CDM,272,RC,,,Outpatient,,,11140,8912,,9469,85,,,percent of total billed charges,85% of total billed charges,2785,100,,,fee schedule,Pays 100% Medicare OPPS,2785,100,,,fee schedule,Pays 100% Medicare OPPS,2785,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2269.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,10026,90,,,percent of total billed charges,90% of total billed charges,3899,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,7653.18,68.7,,,percent of total billed charges,68.7% of total billed charges,8912,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,10026,90,,,fee schedule,Pays 90% Medicare OPPS,6461.2,58,,,percent of total billed charges,58% of total billed charges,2269.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9469,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2000,10026,
STENT WALLFLEX BILIARY RX 10 X 40 8.5FR,1750052,CDM,272,RC,,,Outpatient,,,11140,8912,,9469,85,,,percent of total billed charges,85% of total billed charges,2785,100,,,fee schedule,Pays 100% Medicare OPPS,2785,100,,,fee schedule,Pays 100% Medicare OPPS,2785,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2269.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,10026,90,,,percent of total billed charges,90% of total billed charges,3899,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,7653.18,68.7,,,percent of total billed charges,68.7% of total billed charges,8912,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,10026,90,,,fee schedule,Pays 90% Medicare OPPS,6461.2,58,,,percent of total billed charges,58% of total billed charges,2269.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9469,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2000,10026,
STENT WALLFLEX BILIARY RX 10 X 60 8.5FR,1750057,CDM,272,RC,,,Outpatient,,,11140,8912,,9469,85,,,percent of total billed charges,85% of total billed charges,2785,100,,,fee schedule,Pays 100% Medicare OPPS,2785,100,,,fee schedule,Pays 100% Medicare OPPS,2785,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2269.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,10026,90,,,percent of total billed charges,90% of total billed charges,3899,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,7653.18,68.7,,,percent of total billed charges,68.7% of total billed charges,8912,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,10026,90,,,fee schedule,Pays 90% Medicare OPPS,6461.2,58,,,percent of total billed charges,58% of total billed charges,2269.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9469,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2000,10026,
STENT WALLFLEX BILIARY RX 10 X 80 8.5FR,1750062,CDM,272,RC,,,Outpatient,,,11140,8912,,9469,85,,,percent of total billed charges,85% of total billed charges,2785,100,,,fee schedule,Pays 100% Medicare OPPS,2785,100,,,fee schedule,Pays 100% Medicare OPPS,2785,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2269.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,10026,90,,,percent of total billed charges,90% of total billed charges,3899,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,7653.18,68.7,,,percent of total billed charges,68.7% of total billed charges,8912,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,10026,90,,,fee schedule,Pays 90% Medicare OPPS,6461.2,58,,,percent of total billed charges,58% of total billed charges,2269.22,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9469,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2000,10026,
CORRJ HALUX RIGDUS W/O IMPCT,1528289,CDM,360,RC,28289,HCPCS,Outpatient,,,11160,8928,,9486,85,,,percent of total billed charges,85% of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,3403.66,130,,,fee schedule,Pays 130% Medicare ,2273.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2594.86,102,,,fee schedule,Pays 102% Medicare OPPS,10044,90,,,percent of total billed charges,90% of total billed charges,3906,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,7666.92,68.7,,,percent of total billed charges,68.7% of total billed charges,8928,80,,,percent of total billed charges,80 percent of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2289.59,90,,,fee schedule,Pays 90% Medicare OPPS,6472.8,58,,,percent of total billed charges,58% of total billed charges,2273.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2618.21,100,,,fee schedule,Pays 100% Medicare OPPS,3403.66,130,,,fee schedule,Pays 130% Medicare ,9486,85,,,percent of total billed charges,85% of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,10044,
EXCISE HYDROCELE; BILATERAL,1555041,CDM,360,RC,55041,HCPCS,Outpatient,,,11250,9000,,9562.5,85,,,percent of total billed charges,85% of total billed charges,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,4050.02,130,,,fee schedule,Pays 130% Medicare OPPS,2291.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2915.21,102,,,fee schedule,Pays 102% Medicare OPPS,10125,90,,,percent of total billed charges,90% of total billed charges,3937.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,7728.75,68.7,,,percent of total billed charges,68.7% of total billed charges,9000,80,,,percent of total billed charges,80 percent of total billed charges,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,2572.25,90,,,fee schedule,Pays 90% Medicare OPPS,6525,58,,,percent of total billed charges,58% of total billed charges,2291.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3115.41,100,,,fee schedule,Pays 100% Medicare OPPS,4050.02,130,,,fee schedule,Pays 130% Medicare OPPS,9562.5,85,,,percent of total billed charges,85% of total billed charges,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,10125,
IMPLANT BIOINDUCTIVE W/ARTH DEL MED,1570857,CDM,278,RC,,,Both,,,11408,9126.4,,9696.8,85,,,percent of total billed charges,85% of total billed charges,2852,100,,,fee schedule,Pays 100% Medicare ,2852,100,,,fee schedule,Pays 100% Medicare ,2852,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,2323.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5951.67,52.17,,,case rate,100% of BCBS case rate,5951.67,52.17,,,case rate,100% of BCBS case rate,5951.67,52.17,,,case rate,100% of BCBS case rate,5951.67,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,10267.2,90,,,percent of total billed charges,90% of total billed charges,3992.8,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,7837.3,68.7,,,percent of total billed charges,68.7% of total billed charges,9126.4,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,10267.2,90,,,fee schedule,Pays 90% Medicare ,6616.64,58,,,percent of total billed charges,58% of total billed charges,2323.81,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,9696.8,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2323.81,10267.2,
OR ACUITY LEVEL III 1ST HOUR,1501153,CDM,360,RC,,,Outpatient,,,12160,9728,,10336,85,,,percent of total billed charges,85% of total billed charges,3040,100,,,fee schedule,Pays 100% Medicare OPPS,3040,100,,,fee schedule,Pays 100% Medicare OPPS,3040,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2476.99,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,10944,90,,,percent of total billed charges,90% of total billed charges,4256,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,8353.92,68.7,,,percent of total billed charges,68.7% of total billed charges,9728,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,10944,90,,,fee schedule,Pays 90% Medicare OPPS,7052.8,58,,,percent of total billed charges,58% of total billed charges,2476.99,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10336,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2000,10944,
IMPLANT SYSTEM SPEEDBRG W/BIO-COMP,1570853,CDM,278,RC,,,Both,,,12281,9824.8,,10438.85,85,,,percent of total billed charges,85% of total billed charges,3070.25,100,,,fee schedule,Pays 100% Medicare ,3070.25,100,,,fee schedule,Pays 100% Medicare ,3070.25,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,2501.64,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,6407.12,52.17,,,case rate,100% of BCBS case rate,6407.12,52.17,,,case rate,100% of BCBS case rate,6407.12,52.17,,,case rate,100% of BCBS case rate,6407.12,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,11052.9,90,,,percent of total billed charges,90% of total billed charges,4298.35,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,8437.05,68.7,,,percent of total billed charges,68.7% of total billed charges,9824.8,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,11052.9,90,,,fee schedule,Pays 90% Medicare ,7122.98,58,,,percent of total billed charges,58% of total billed charges,2501.64,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10438.85,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2501.64,11052.9,
NF-LUPRON DEPOT (LEUPROLIDE) INJ:11.25MG,2605099,CDM,636,RC,J1950,HCPCS,Both,,,12485,9988,,10612.25,85,,,percent of total billed charges,85% of total billed charges,1477.55,100,,,fee schedule,Pays 100% Medicare ,1477.55,100,,,fee schedule,Pays 100% Medicare ,1477.55,100,,,fee schedule,Pays 100% Medicare ,1981.64,130,,,fee schedule,Pays 130% Medicare OPPS,1778.53,120.37,,,fee schedule,120.37% of custom fee schedule,6513.55,52.17,,,case rate,100% of BCBS case rate,6513.55,52.17,,,case rate,100% of BCBS case rate,6513.55,52.17,,,case rate,100% of BCBS case rate,6513.55,52.17,,,case rate,100% of BCBS case rate,1507.1,102,,,fee schedule,Pays 102% Medicare ,11236.5,90,,,percent of total billed charges,90% of total billed charges,1849.6,125.18,,,fee schedule,125.18% of custom fee schedule,8577.2,68.7,,,percent of total billed charges,68.7% of total billed charges,9988,80,,,percent of total billed charges,80 percent of total billed charges,1477.55,100,,,fee schedule,Pays 100% Medicare ,1329.79,90,,,fee schedule,Pays 90% Medicare ,7241.3,58,,,percent of total billed charges,58% of total billed charges,1778.53,120.37,,,fee schedule,120.37% of custom fee schedule,1524.34,100,,,fee schedule,Pays 100% Medicare ,1981.64,130,,,fee schedule,Pays 130% Medicare OPPS,10612.25,85,,,percent of total billed charges,85% of total billed charges,1477.55,100,,,fee schedule,Pays 100% Medicare ,1329.79,11236.5,
FREEING OF BOWEL ADHESION,1544005,CDM,360,RC,44005,HCPCS,Outpatient,,,12500,10000,,10625,85,,,percent of total billed charges,85% of total billed charges,12500,100,,,fee schedule,Pays 100% Medicare OPPS,12500,100,,,fee schedule,Pays 100% Medicare OPPS,12500,100,,,fee schedule,Pays 100% Medicare OPPS,12500,130,,,fee schedule,Pays 130% Medicare OPPS,2546.25,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,12500,102,,,fee schedule,Pays 102% Medicare OPPS,11250,90,,,percent of total billed charges,90% of total billed charges,4375,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,8587.5,68.7,,,percent of total billed charges,68.7% of total billed charges,10000,80,,,percent of total billed charges,80 percent of total billed charges,12500,100,,,fee schedule,Pays 100% Medicare OPPS,12500,90,,,fee schedule,Pays 90% Medicare OPPS,7250,58,,,percent of total billed charges,58% of total billed charges,2546.25,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,12500,100,,,fee schedule,Pays 100% Medicare OPPS,12500,130,,,fee schedule,Pays 130% Medicare OPPS,10625,85,,,percent of total billed charges,85% of total billed charges,12500,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,12500,
MOBILIZATION OF COLON,1544139,CDM,360,RC,44139,HCPCS,Outpatient,,,12500,10000,,10625,85,,,percent of total billed charges,85% of total billed charges,12500,100,,,fee schedule,Pays 100% Medicare OPPS,12500,100,,,fee schedule,Pays 100% Medicare OPPS,12500,100,,,fee schedule,Pays 100% Medicare OPPS,12500,130,APC,,fee schedule,Pays 130% Medicare OPPS,2546.25,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,12500,102,,,fee schedule,Pays 102% Medicare OPPS,11250,90,,,percent of total billed charges,90% of total billed charges,4375,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,8587.5,68.7,,,percent of total billed charges,68.7% of total billed charges,10000,80,,,percent of total billed charges,80 percent of total billed charges,12500,100,,,fee schedule,Pays 100% Medicare OPPS,12500,90,,,fee schedule,Pays 90% Medicare OPPS,7250,58,,,percent of total billed charges,58% of total billed charges,2546.25,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,12500,100,,,fee schedule,Pays 100% Medicare OPPS,12500,130,APC,,fee schedule,Pays 130% Medicare OPPS,10625,85,,,percent of total billed charges,85% of total billed charges,12500,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,12500,
LAP PARTIAL COLECTOMY,1544204,CDM,360,RC,44204,HCPCS,Outpatient,,,12500,10000,,10625,85,,,percent of total billed charges,85% of total billed charges,12500,100,,,fee schedule,Pays 100% Medicare OPPS,12500,100,,,fee schedule,Pays 100% Medicare OPPS,12500,100,,,fee schedule,Pays 100% Medicare OPPS,12500,130,,,fee schedule,Pays 130% Medicare OPPS,2546.25,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,12500,102,,,fee schedule,Pays 102% Medicare OPPS,11250,90,,,percent of total billed charges,90% of total billed charges,4375,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,8587.5,68.7,,,percent of total billed charges,68.7% of total billed charges,10000,80,,,percent of total billed charges,80 percent of total billed charges,12500,100,,,fee schedule,Pays 100% Medicare OPPS,12500,90,,,fee schedule,Pays 90% Medicare OPPS,7250,58,,,percent of total billed charges,58% of total billed charges,2546.25,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,12500,100,,,fee schedule,Pays 100% Medicare OPPS,12500,130,,,fee schedule,Pays 130% Medicare OPPS,10625,85,,,percent of total billed charges,85% of total billed charges,12500,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,12500,
HAMMERTOE OP ONE TOE,1528285,CDM,360,RC,28285,HCPCS,Outpatient,,,12815,10252,,10892.75,85,,,percent of total billed charges,85% of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,3403.66,130,,,fee schedule,Pays 130% Medicare OPPS,2610.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2594.86,102,,,fee schedule,Pays 102% Medicare OPPS,11533.5,90,,,percent of total billed charges,90% of total billed charges,4485.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,8803.91,68.7,,,percent of total billed charges,68.7% of total billed charges,10252,80,,,percent of total billed charges,80 percent of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2289.59,90,,,fee schedule,Pays 90% Medicare OPPS,7432.7,58,,,percent of total billed charges,58% of total billed charges,2610.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2618.21,100,,,fee schedule,Pays 100% Medicare OPPS,3403.66,130,,,fee schedule,Pays 130% Medicare OPPS,10892.75,85,,,percent of total billed charges,85% of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,11533.5,
INS TUNNELED CVAD W PORT 5YRS/>,1536561,CDM,360,RC,,,Outpatient,,,12815,10252,,10892.75,85,,,percent of total billed charges,85% of total billed charges,3203.75,100,,,fee schedule,Pays 100% Medicare OPPS,3203.75,100,,,fee schedule,Pays 100% Medicare OPPS,3203.75,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2610.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,11533.5,90,,,percent of total billed charges,90% of total billed charges,4485.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,8803.91,68.7,,,percent of total billed charges,68.7% of total billed charges,10252,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,11533.5,90,,,fee schedule,Pays 90% Medicare OPPS,7432.7,58,,,percent of total billed charges,58% of total billed charges,2610.42,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,10892.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2000,11533.5,
MUSCLE FLAP TRUNK,1515734,CDM,360,RC,15734,HCPCS,Outpatient,,,13125,10500,,11156.25,85,,,percent of total billed charges,85% of total billed charges,3163.16,100,,,fee schedule,Pays 100% Medicare OPPS,3163.16,100,,,fee schedule,Pays 100% Medicare OPPS,3163.16,100,,,fee schedule,Pays 100% Medicare OPPS,3719.69,130,,,fee schedule,Pays 130% Medicare OPPS,2673.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,3226.42,102,,,fee schedule,Pays 102% Medicare OPPS,11812.5,90,,,percent of total billed charges,90% of total billed charges,4593.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,9016.88,68.7,,,percent of total billed charges,68.7% of total billed charges,10500,80,,,percent of total billed charges,80 percent of total billed charges,3163.16,100,,,fee schedule,Pays 100% Medicare OPPS,2846.84,90,,,fee schedule,Pays 90% Medicare OPPS,7612.5,58,,,percent of total billed charges,58% of total billed charges,2673.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2861.3,100,,,fee schedule,Pays 100% Medicare OPPS,3719.69,130,,,fee schedule,Pays 130% Medicare OPPS,11156.25,85,,,percent of total billed charges,85% of total billed charges,3163.16,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,11812.5,
REMOVAL OF BREAST LESION,1519120,CDM,360,RC,19120,HCPCS,Outpatient,,,13440,10752,,11424,85,,,percent of total billed charges,85% of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,3930.96,130,,,fee schedule,Pays 130% Medicare OPPS,2737.73,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2893.37,102,,,fee schedule,Pays 102% Medicare OPPS,12096,90,,,percent of total billed charges,90% of total billed charges,4704,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,9233.28,68.7,,,percent of total billed charges,68.7% of total billed charges,10752,80,,,percent of total billed charges,80 percent of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2552.98,90,,,fee schedule,Pays 90% Medicare OPPS,7795.2,58,,,percent of total billed charges,58% of total billed charges,2737.73,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3023.82,100,,,fee schedule,Pays 100% Medicare OPPS,3930.96,130,,,fee schedule,Pays 130% Medicare OPPS,11424,85,,,percent of total billed charges,85% of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,12096,
PARTIAL MASTECTOMY,1519301,CDM,360,RC,19301,HCPCS,Outpatient,,,13440,10752,,11424,85,,,percent of total billed charges,85% of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,3930.96,130,,,fee schedule,Pays 130% Medicare OPPS,2737.73,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2893.37,102,,,fee schedule,Pays 102% Medicare OPPS,12096,90,,,percent of total billed charges,90% of total billed charges,4704,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,9233.28,68.7,,,percent of total billed charges,68.7% of total billed charges,10752,80,,,percent of total billed charges,80 percent of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2552.98,90,,,fee schedule,Pays 90% Medicare OPPS,7795.2,58,,,percent of total billed charges,58% of total billed charges,2737.73,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3023.82,100,,,fee schedule,Pays 100% Medicare OPPS,3930.96,130,,,fee schedule,Pays 130% Medicare OPPS,11424,85,,,percent of total billed charges,85% of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,12096,
REMOVAL INTACT BREAST IMPLANT,1519328,CDM,360,RC,19328,HCPCS,Outpatient,,,13440,10752,,11424,85,,,percent of total billed charges,85% of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,3930.96,130,,,fee schedule,Pays 130% Medicare OPPS,2737.73,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2893.37,102,,,fee schedule,Pays 102% Medicare OPPS,12096,90,,,percent of total billed charges,90% of total billed charges,4704,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,9233.28,68.7,,,percent of total billed charges,68.7% of total billed charges,10752,80,,,percent of total billed charges,80 percent of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2552.98,90,,,fee schedule,Pays 90% Medicare OPPS,7795.2,58,,,percent of total billed charges,58% of total billed charges,2737.73,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3023.82,100,,,fee schedule,Pays 100% Medicare OPPS,3930.96,130,,,fee schedule,Pays 130% Medicare OPPS,11424,85,,,percent of total billed charges,85% of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,12096,
PERIPROSTH CAPSULECT BREAST,1519371,CDM,360,RC,19371,HCPCS,Outpatient,,,13440,10752,,11424,85,,,percent of total billed charges,85% of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,3930.96,130,,,fee schedule,Pays 130% Medicare OPPS,2737.73,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2893.37,102,,,fee schedule,Pays 102% Medicare OPPS,12096,90,,,percent of total billed charges,90% of total billed charges,4704,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,9233.28,68.7,,,percent of total billed charges,68.7% of total billed charges,10752,80,,,percent of total billed charges,80 percent of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2552.98,90,,,fee schedule,Pays 90% Medicare OPPS,7795.2,58,,,percent of total billed charges,58% of total billed charges,2737.73,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3023.82,100,,,fee schedule,Pays 100% Medicare OPPS,3930.96,130,,,fee schedule,Pays 130% Medicare OPPS,11424,85,,,percent of total billed charges,85% of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,12096,
OPEN BX/EXC AXILLARY NODE,1538525,CDM,360,RC,38525,HCPCS,Outpatient,,,13440,10752,,11424,85,,,percent of total billed charges,85% of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,3930.96,130,,,fee schedule,Pays 130% Medicare OPPS,2737.73,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2893.37,102,,,fee schedule,Pays 102% Medicare OPPS,12096,90,,,percent of total billed charges,90% of total billed charges,4704,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,9233.28,68.7,,,percent of total billed charges,68.7% of total billed charges,10752,80,,,percent of total billed charges,80 percent of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2552.98,90,,,fee schedule,Pays 90% Medicare OPPS,7795.2,58,,,percent of total billed charges,58% of total billed charges,2737.73,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3023.82,100,,,fee schedule,Pays 100% Medicare OPPS,3930.96,130,,,fee schedule,Pays 130% Medicare OPPS,11424,85,,,percent of total billed charges,85% of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,12096,
BIOPSY BREAST OPEN INCISIONAL,1519101,CDM,360,RC,19101,HCPCS,Outpatient,,,13815,11052,,11742.75,85,,,percent of total billed charges,85% of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,3930.96,130,,,fee schedule,Pays 130% Medicare OPPS,2814.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2893.37,102,,,fee schedule,Pays 102% Medicare OPPS,12433.5,90,,,percent of total billed charges,90% of total billed charges,4835.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,9490.91,68.7,,,percent of total billed charges,68.7% of total billed charges,11052,80,,,percent of total billed charges,80 percent of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2552.98,90,,,fee schedule,Pays 90% Medicare OPPS,8012.7,58,,,percent of total billed charges,58% of total billed charges,2814.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3023.82,100,,,fee schedule,Pays 100% Medicare OPPS,3930.96,130,,,fee schedule,Pays 130% Medicare OPPS,11742.75,85,,,percent of total billed charges,85% of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,12433.5,
OPEN BX OR EXC LN; SUPERFICIAL,1538500,CDM,360,RC,38500,HCPCS,Outpatient,,,13815,11052,,11742.75,85,,,percent of total billed charges,85% of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,3930.96,130,,,fee schedule,Pays 130% Medicare OPPS,2814.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2893.37,102,,,fee schedule,Pays 102% Medicare OPPS,12433.5,90,,,percent of total billed charges,90% of total billed charges,4835.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,9490.91,68.7,,,percent of total billed charges,68.7% of total billed charges,11052,80,,,percent of total billed charges,80 percent of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,2552.98,90,,,fee schedule,Pays 90% Medicare OPPS,8012.7,58,,,percent of total billed charges,58% of total billed charges,2814.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3023.82,100,,,fee schedule,Pays 100% Medicare OPPS,3930.96,130,,,fee schedule,Pays 130% Medicare OPPS,11742.75,85,,,percent of total billed charges,85% of total billed charges,2836.64,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,12433.5,
RPR UMBIL HERN BLOCK 5+ YR,1549587,CDM,360,RC,49587,HCPCS,Outpatient,,,13815,11052,,11742.75,85,,,percent of total billed charges,85% of total billed charges,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2814.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2915.21,102,,,fee schedule,Pays 102% Medicare OPPS,12433.5,90,,,percent of total billed charges,90% of total billed charges,4835.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,9490.91,68.7,,,percent of total billed charges,68.7% of total billed charges,11052,80,,,percent of total billed charges,80 percent of total billed charges,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,2572.25,90,,,fee schedule,Pays 90% Medicare OPPS,8012.7,58,,,percent of total billed charges,58% of total billed charges,2814.12,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,11742.75,85,,,percent of total billed charges,85% of total billed charges,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,12433.5,
RPR VENTRAL HERN INIT REDUC,1549560,CDM,360,RC,49560,HCPCS,Outpatient,,,13940,11152,,11849,85,,,percent of total billed charges,85% of total billed charges,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2839.58,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2915.21,102,,,fee schedule,Pays 102% Medicare OPPS,12546,90,,,percent of total billed charges,90% of total billed charges,4879,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,9576.78,68.7,,,percent of total billed charges,68.7% of total billed charges,11152,80,,,percent of total billed charges,80 percent of total billed charges,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,2572.25,90,,,fee schedule,Pays 90% Medicare OPPS,8085.2,58,,,percent of total billed charges,58% of total billed charges,2839.58,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,11849,85,,,percent of total billed charges,85% of total billed charges,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,12546,
REPAIR INITIAL INCISIONAL HERNIA INCARC,1549561,CDM,360,RC,49561,HCPCS,Outpatient,,,13940,11152,,11849,85,,,percent of total billed charges,85% of total billed charges,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2839.58,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2915.21,102,,,fee schedule,Pays 102% Medicare OPPS,12546,90,,,percent of total billed charges,90% of total billed charges,4879,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,9576.78,68.7,,,percent of total billed charges,68.7% of total billed charges,11152,80,,,percent of total billed charges,80 percent of total billed charges,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,2572.25,90,,,fee schedule,Pays 90% Medicare OPPS,8085.2,58,,,percent of total billed charges,58% of total billed charges,2839.58,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,11849,85,,,percent of total billed charges,85% of total billed charges,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,12546,
REP INIT FEM HERNIA REDUCABLE; INCARCE,1549553,CDM,360,RC,49553,HCPCS,Outpatient,,,13950,11160,,11857.5,85,,,percent of total billed charges,85% of total billed charges,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,4050.02,130,,,fee schedule,Pays 130% Medicare OPPS,2841.62,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2915.21,102,,,fee schedule,Pays 102% Medicare OPPS,12555,90,,,percent of total billed charges,90% of total billed charges,4882.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,9583.65,68.7,,,percent of total billed charges,68.7% of total billed charges,11160,80,,,percent of total billed charges,80 percent of total billed charges,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,2572.25,90,,,fee schedule,Pays 90% Medicare OPPS,8091,58,,,percent of total billed charges,58% of total billed charges,2841.62,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3115.41,100,,,fee schedule,Pays 100% Medicare OPPS,4050.02,130,,,fee schedule,Pays 130% Medicare OPPS,11857.5,85,,,percent of total billed charges,85% of total billed charges,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,12555,
Repair of groin hernia patient age 5 years or older,1549505,CDM,360,RC,49505,HCPCS,Outpatient,,,14065,11252,,11955.25,85,,,percent of total billed charges,85% of total billed charges,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,4050.02,130,,,fee schedule,Pays 130% Medicare ,2865.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2915.21,102,,,fee schedule,Pays 102% Medicare OPPS,12658.5,90,,,percent of total billed charges,90% of total billed charges,4922.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,9662.66,68.7,,,percent of total billed charges,68.7% of total billed charges,11252,80,,,percent of total billed charges,80 percent of total billed charges,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,2572.25,90,,,fee schedule,Pays 90% Medicare OPPS,8157.7,58,,,percent of total billed charges,58% of total billed charges,2865.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,3115.41,100,,,fee schedule,Pays 100% Medicare OPPS,4050.02,130,,,fee schedule,Pays 130% Medicare ,11955.25,85,,,percent of total billed charges,85% of total billed charges,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,12658.5,
Repair of umbilical hernia in patients over 5 years old,1549585,CDM,360,RC,49585,HCPCS,Outpatient,,,14065,11252,,11955.25,85,,,percent of total billed charges,85% of total billed charges,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2865.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2915.21,102,,,fee schedule,Pays 102% Medicare OPPS,12658.5,90,,,percent of total billed charges,90% of total billed charges,4922.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,9662.66,68.7,,,percent of total billed charges,68.7% of total billed charges,11252,80,,,percent of total billed charges,80 percent of total billed charges,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,2572.25,90,,,fee schedule,Pays 90% Medicare OPPS,8157.7,58,,,percent of total billed charges,58% of total billed charges,2865.04,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,11955.25,85,,,percent of total billed charges,85% of total billed charges,2858.06,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,12658.5,
RETAVASE (RETEPLASE) 20 UNITS KIT,2605047,CDM,636,RC,J2993,HCPCS,Both,,,14290,11432,,12146.5,85,,,percent of total billed charges,85% of total billed charges,2491.03,100,,,fee schedule,Pays 100% Medicare ,2491.03,100,,,fee schedule,Pays 100% Medicare ,2491.03,100,,,fee schedule,Pays 100% Medicare ,3624.38,130,,,fee schedule,Pays 130% Medicare OPPS,2910.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,7455.24,52.17,,,case rate,100% of BCBS case rate,7455.24,52.17,,,case rate,100% of BCBS case rate,7455.24,52.17,,,case rate,100% of BCBS case rate,7455.24,52.17,,,case rate,100% of BCBS case rate,2540.85,102,,,fee schedule,Pays 102% Medicare ,12861,90,,,percent of total billed charges,90% of total billed charges,5001.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,9817.23,68.7,,,percent of total billed charges,68.7% of total billed charges,11432,80,,,percent of total billed charges,80 percent of total billed charges,2491.03,100,,,fee schedule,Pays 100% Medicare ,2241.92,90,,,fee schedule,Pays 90% Medicare ,8288.2,58,,,percent of total billed charges,58% of total billed charges,2910.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2787.99,100,,,fee schedule,Pays 100% Medicare ,3624.38,130,,,fee schedule,Pays 130% Medicare OPPS,12146.5,85,,,percent of total billed charges,85% of total billed charges,2491.03,100,,,fee schedule,Pays 100% Medicare ,2241.92,12861,
OR ACUITY LEVEL IV 1ST HOUR,1501155,CDM,360,RC,,,Outpatient,,,14610,11688,,12418.5,85,,,percent of total billed charges,85% of total billed charges,3652.5,100,,,fee schedule,Pays 100% Medicare OPPS,3652.5,100,,,fee schedule,Pays 100% Medicare OPPS,3652.5,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,2976.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,13149,90,,,percent of total billed charges,90% of total billed charges,5113.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10037.07,68.7,,,percent of total billed charges,68.7% of total billed charges,11688,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,13149,90,,,fee schedule,Pays 90% Medicare OPPS,8473.8,58,,,percent of total billed charges,58% of total billed charges,2976.06,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,12418.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2000,13149,
SHO ARTHR SRG LMTD DRBDMT,1529822,CDM,360,RC,29822,HCPCS,Outpatient,,,15250,12200,,12962.5,85,,,percent of total billed charges,85% of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,3403.66,130,,,fee schedule,Pays 130% Medicare OPPS,3106.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2594.86,102,,,fee schedule,Pays 102% Medicare OPPS,13725,90,,,percent of total billed charges,90% of total billed charges,5337.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10476.75,68.7,,,percent of total billed charges,68.7% of total billed charges,12200,80,,,percent of total billed charges,80 percent of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2289.59,90,,,fee schedule,Pays 90% Medicare OPPS,8845,58,,,percent of total billed charges,58% of total billed charges,3106.43,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2618.21,100,,,fee schedule,Pays 100% Medicare OPPS,3403.66,130,,,fee schedule,Pays 130% Medicare OPPS,12962.5,85,,,percent of total billed charges,85% of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,13725,
ERCP DUCT STENT PLACEMENT,1743274,CDM,750,RC,43274,HCPCS,Outpatient,,,15750,12600,,13387.5,85,,,percent of total billed charges,85% of total billed charges,4521.78,100,,,fee schedule,Pays 100% Medicare OPPS,4521.78,100,,,fee schedule,Pays 100% Medicare OPPS,4521.78,100,,,fee schedule,Pays 100% Medicare OPPS,5992.51,130,,,fee schedule,Pays 130% Medicare OPPS,3208.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,4612.21,102,,,fee schedule,Pays 102% Medicare OPPS,14175,90,,,percent of total billed charges,90% of total billed charges,5512.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10820.25,68.7,,,percent of total billed charges,68.7% of total billed charges,12600,80,,,percent of total billed charges,80 percent of total billed charges,4521.78,100,,,fee schedule,Pays 100% Medicare OPPS,4069.6,90,,,fee schedule,Pays 90% Medicare OPPS,9135,58,,,percent of total billed charges,58% of total billed charges,3208.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4609.63,100,,,fee schedule,Pays 100% Medicare OPPS,5992.51,130,,,fee schedule,Pays 130% Medicare OPPS,13387.5,85,,,percent of total billed charges,85% of total billed charges,4521.78,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,14175,
ERCP STENT EXCHANGE W/DILATE,1743276,CDM,750,RC,43276,HCPCS,Outpatient,,,15750,12600,,13387.5,85,,,percent of total billed charges,85% of total billed charges,4521.78,100,,,fee schedule,Pays 100% Medicare OPPS,4521.78,100,,,fee schedule,Pays 100% Medicare OPPS,4521.78,100,,,fee schedule,Pays 100% Medicare OPPS,5992.51,130,,,fee schedule,Pays 130% Medicare OPPS,3208.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,4612.21,102,,,fee schedule,Pays 102% Medicare OPPS,14175,90,,,percent of total billed charges,90% of total billed charges,5512.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10820.25,68.7,,,percent of total billed charges,68.7% of total billed charges,12600,80,,,percent of total billed charges,80 percent of total billed charges,4521.78,100,,,fee schedule,Pays 100% Medicare OPPS,4069.6,90,,,fee schedule,Pays 90% Medicare OPPS,9135,58,,,percent of total billed charges,58% of total billed charges,3208.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4609.63,100,,,fee schedule,Pays 100% Medicare OPPS,5992.51,130,,,fee schedule,Pays 130% Medicare OPPS,13387.5,85,,,percent of total billed charges,85% of total billed charges,4521.78,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,14175,
COLONOSCOPY W STENT PLACEMENT,1745389,CDM,750,RC,45389,HCPCS,Outpatient,,,15750,12600,,13387.5,85,,,percent of total billed charges,85% of total billed charges,4521.78,100,,,fee schedule,Pays 100% Medicare OPPS,4521.78,100,,,fee schedule,Pays 100% Medicare OPPS,4521.78,100,,,fee schedule,Pays 100% Medicare OPPS,5992.51,130,,,fee schedule,Pays 130% Medicare OPPS,3208.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,4612.21,102,,,fee schedule,Pays 102% Medicare OPPS,14175,90,,,percent of total billed charges,90% of total billed charges,5512.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,10820.25,68.7,,,percent of total billed charges,68.7% of total billed charges,12600,80,,,percent of total billed charges,80 percent of total billed charges,4521.78,100,,,fee schedule,Pays 100% Medicare OPPS,4069.6,90,,,fee schedule,Pays 90% Medicare OPPS,9135,58,,,percent of total billed charges,58% of total billed charges,3208.28,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4609.63,100,,,fee schedule,Pays 100% Medicare OPPS,5992.51,130,,,fee schedule,Pays 130% Medicare OPPS,13387.5,85,,,percent of total billed charges,85% of total billed charges,4521.78,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,14175,
INCISE FOOT/TOE FASCIA,1528008,CDM,360,RC,28008,HCPCS,Outpatient,,,16565,13252,,14080.25,85,,,percent of total billed charges,85% of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,3403.66,130,,,fee schedule,Pays 130% Medicare OPPS,3374.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2594.86,102,,,fee schedule,Pays 102% Medicare OPPS,14908.5,90,,,percent of total billed charges,90% of total billed charges,5797.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,11380.16,68.7,,,percent of total billed charges,68.7% of total billed charges,13252,80,,,percent of total billed charges,80 percent of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2289.59,90,,,fee schedule,Pays 90% Medicare OPPS,9607.7,58,,,percent of total billed charges,58% of total billed charges,3374.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2618.21,100,,,fee schedule,Pays 100% Medicare OPPS,3403.66,130,,,fee schedule,Pays 130% Medicare OPPS,14080.25,85,,,percent of total billed charges,85% of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,14908.5,
PARTIAL EXC PHALANX TOE BONE,1528124,CDM,360,RC,28124,HCPCS,Outpatient,,,16565,13252,,14080.25,85,,,percent of total billed charges,85% of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,3403.66,130,,,fee schedule,Pays 130% Medicare OPPS,3374.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2594.86,102,,,fee schedule,Pays 102% Medicare OPPS,14908.5,90,,,percent of total billed charges,90% of total billed charges,5797.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,11380.16,68.7,,,percent of total billed charges,68.7% of total billed charges,13252,80,,,percent of total billed charges,80 percent of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2289.59,90,,,fee schedule,Pays 90% Medicare OPPS,9607.7,58,,,percent of total billed charges,58% of total billed charges,3374.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2618.21,100,,,fee schedule,Pays 100% Medicare OPPS,3403.66,130,,,fee schedule,Pays 130% Medicare OPPS,14080.25,85,,,percent of total billed charges,85% of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,14908.5,
CORRECTION HALLUX VALGUS,1528292,CDM,360,RC,28292,HCPCS,Outpatient,,,16565,13252,,14080.25,85,,,percent of total billed charges,85% of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,3403.66,130,,,fee schedule,Pays 130% Medicare OPPS,3374.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2594.86,102,,,fee schedule,Pays 102% Medicare OPPS,14908.5,90,,,percent of total billed charges,90% of total billed charges,5797.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,11380.16,68.7,,,percent of total billed charges,68.7% of total billed charges,13252,80,,,percent of total billed charges,80 percent of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2289.59,90,,,fee schedule,Pays 90% Medicare OPPS,9607.7,58,,,percent of total billed charges,58% of total billed charges,3374.29,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2618.21,100,,,fee schedule,Pays 100% Medicare OPPS,3403.66,130,,,fee schedule,Pays 130% Medicare OPPS,14080.25,85,,,percent of total billed charges,85% of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,14908.5,
EGD ENDOSCOPIC STENT PLACEMENT,1743266,CDM,750,RC,43266,HCPCS,Outpatient,,,16865,13492,,14335.25,85,,,percent of total billed charges,85% of total billed charges,4521.78,100,,,fee schedule,Pays 100% Medicare OPPS,4521.78,100,,,fee schedule,Pays 100% Medicare OPPS,4521.78,100,,,fee schedule,Pays 100% Medicare OPPS,5992.51,130,,,fee schedule,Pays 130% Medicare OPPS,3435.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,4612.21,102,,,fee schedule,Pays 102% Medicare OPPS,15178.5,90,,,percent of total billed charges,90% of total billed charges,5902.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,11586.26,68.7,,,percent of total billed charges,68.7% of total billed charges,13492,80,,,percent of total billed charges,80 percent of total billed charges,4521.78,100,,,fee schedule,Pays 100% Medicare OPPS,4069.6,90,,,fee schedule,Pays 90% Medicare OPPS,9781.7,58,,,percent of total billed charges,58% of total billed charges,3435.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4609.63,100,,,fee schedule,Pays 100% Medicare OPPS,5992.51,130,,,fee schedule,Pays 130% Medicare OPPS,14335.25,85,,,percent of total billed charges,85% of total billed charges,4521.78,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,15178.5,
SHO ARTHRS SRG DSTL CLAVICLC,1529824,CDM,360,RC,29824,HCPCS,Outpatient,,,17250,13800,,14662.5,85,,,percent of total billed charges,85% of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,3403.66,130,,,fee schedule,Pays 130% Medicare OPPS,3513.83,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2594.86,102,,,fee schedule,Pays 102% Medicare OPPS,15525,90,,,percent of total billed charges,90% of total billed charges,6037.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,11850.75,68.7,,,percent of total billed charges,68.7% of total billed charges,13800,80,,,percent of total billed charges,80 percent of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2289.59,90,,,fee schedule,Pays 90% Medicare OPPS,10005,58,,,percent of total billed charges,58% of total billed charges,3513.83,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2618.21,100,,,fee schedule,Pays 100% Medicare OPPS,3403.66,130,,,fee schedule,Pays 130% Medicare OPPS,14662.5,85,,,percent of total billed charges,85% of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,15525,
"Removal of either benign or malignant tissue from the uterus, ovaries, fallopian tubes, or any of the surrounding tissues using a laparoscope",1558661,CDM,360,RC,58661,HCPCS,Outpatient,,,17500,14000,,14875,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,3564.75,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,4636.3,102,,,fee schedule,Pays 102% Medicare OPPS,15750,90,,,percent of total billed charges,90% of total billed charges,6125,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,12022.5,68.7,,,percent of total billed charges,68.7% of total billed charges,14000,80,,,percent of total billed charges,80 percent of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4090.85,90,,,fee schedule,Pays 90% Medicare OPPS,10150,58,,,percent of total billed charges,58% of total billed charges,3564.75,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4584.49,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,14875,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,15750,
PARTIAL THYROID EXCISION,1560210,CDM,360,RC,60210,HCPCS,Outpatient,,,18000,14400,,15300,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,3666.6,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,4636.3,102,,,fee schedule,Pays 102% Medicare OPPS,16200,90,,,percent of total billed charges,90% of total billed charges,6300,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,12366,68.7,,,percent of total billed charges,68.7% of total billed charges,14400,80,,,percent of total billed charges,80 percent of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4090.85,90,,,fee schedule,Pays 90% Medicare OPPS,10440,58,,,percent of total billed charges,58% of total billed charges,3666.6,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4584.49,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,15300,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,16200,
PARTIAL REMOVAL OF COLON,1544140,CDM,360,RC,44140,HCPCS,Outpatient,,,18500,14800,,15725,85,,,percent of total billed charges,85% of total billed charges,18500,100,,,fee schedule,Pays 100% Medicare OPPS,18500,100,,,fee schedule,Pays 100% Medicare OPPS,18500,100,,,fee schedule,Pays 100% Medicare OPPS,18500,130,,,fee schedule,Pays 130% Medicare OPPS,3768.45,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,18500,102,,,fee schedule,Pays 102% Medicare OPPS,16650,90,,,percent of total billed charges,90% of total billed charges,6475,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,12709.5,68.7,,,percent of total billed charges,68.7% of total billed charges,14800,80,,,percent of total billed charges,80 percent of total billed charges,18500,100,,,fee schedule,Pays 100% Medicare OPPS,18500,90,,,fee schedule,Pays 90% Medicare OPPS,10730,58,,,percent of total billed charges,58% of total billed charges,3768.45,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,18500,100,,,fee schedule,Pays 100% Medicare OPPS,18500,130,,,fee schedule,Pays 130% Medicare OPPS,15725,85,,,percent of total billed charges,85% of total billed charges,18500,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,18500,
PARTIAL THYROID EXCISION,1560212,CDM,360,RC,60212,HCPCS,Outpatient,,,18500,14800,,15725,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,3768.45,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,4636.3,102,,,fee schedule,Pays 102% Medicare OPPS,16650,90,,,percent of total billed charges,90% of total billed charges,6475,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,12709.5,68.7,,,percent of total billed charges,68.7% of total billed charges,14800,80,,,percent of total billed charges,80 percent of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4090.85,90,,,fee schedule,Pays 90% Medicare OPPS,10730,58,,,percent of total billed charges,58% of total billed charges,3768.45,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4584.49,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,15725,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,16650,
ACTIVASE (ALTEPLASE) 100MG VIAL,2605133,CDM,250,RC,,,Outpatient,,,19425,15540,,16511.25,85,,,percent of total billed charges,85% of total billed charges,4856.25,100,,,fee schedule,Pays 100% Medicare OPPS,4856.25,100,,,fee schedule,Pays 100% Medicare OPPS,4856.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,3956.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,,,,,other,Not reimbursable per contract,17482.5,90,,,percent of total billed charges,90% of total billed charges,6798.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13344.98,68.7,,,percent of total billed charges,68.7% of total billed charges,15540,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,17482.5,90,,,fee schedule,Pays 90% Medicare OPPS,11266.5,58,,,percent of total billed charges,58% of total billed charges,3956.87,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,16511.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,2000,17482.5,
SHO ARTHRS SRG BICP TENODSIS,1529828,CDM,360,RC,29828,HCPCS,Outpatient,,,19500,15600,,16575,85,,,percent of total billed charges,85% of total billed charges,5626.71,100,,,fee schedule,Pays 100% Medicare OPPS,5626.71,100,,,fee schedule,Pays 100% Medicare OPPS,5626.71,100,,,fee schedule,Pays 100% Medicare OPPS,7563.51,130,,,fee schedule,Pays 130% Medicare OPPS,3972.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,5739.25,102,,,fee schedule,Pays 102% Medicare OPPS,17550,90,,,percent of total billed charges,90% of total billed charges,6825,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13396.5,68.7,,,percent of total billed charges,68.7% of total billed charges,15600,80,,,percent of total billed charges,80 percent of total billed charges,5626.71,100,,,fee schedule,Pays 100% Medicare OPPS,5064.04,90,,,fee schedule,Pays 90% Medicare OPPS,11310,58,,,percent of total billed charges,58% of total billed charges,3972.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5818.09,100,,,fee schedule,Pays 100% Medicare OPPS,7563.51,130,,,fee schedule,Pays 130% Medicare OPPS,16575,85,,,percent of total billed charges,85% of total billed charges,5626.71,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,17550,
TNKASE IV (TENECTEPLASE) INJ 50MG,2605126,CDM,636,RC,J3101,HCPCS,Both,,,19765,15812,,16800.25,85,,,percent of total billed charges,85% of total billed charges,143.87,100,,,fee schedule,Pays 100% Medicare ,143.87,100,,,fee schedule,Pays 100% Medicare ,143.87,100,,,fee schedule,Pays 100% Medicare ,199.03,130,,,fee schedule,Pays 130% Medicare OPPS,4026.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,10311.6,52.17,,,case rate,100% of BCBS case rate,10311.6,52.17,,,case rate,100% of BCBS case rate,10311.6,52.17,,,case rate,100% of BCBS case rate,10311.6,52.17,,,case rate,100% of BCBS case rate,146.74,102,,,fee schedule,Pays 102% Medicare ,17788.5,90,,,percent of total billed charges,90% of total billed charges,6917.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13578.56,68.7,,,percent of total billed charges,68.7% of total billed charges,15812,80,,,percent of total billed charges,80 percent of total billed charges,143.87,100,,,fee schedule,Pays 100% Medicare ,129.47,90,,,fee schedule,Pays 90% Medicare ,11463.7,58,,,percent of total billed charges,58% of total billed charges,4026.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,153.1,100,,,fee schedule,Pays 100% Medicare ,199.03,130,,,fee schedule,Pays 130% Medicare OPPS,16800.25,85,,,percent of total billed charges,85% of total billed charges,143.87,100,,,fee schedule,Pays 100% Medicare ,129.47,17788.5,
LAP ENTEROLYSIS,1544180,CDM,360,RC,44180,HCPCS,Outpatient,,,20000,16000,,17000,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,4074,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,4636.3,102,,,fee schedule,Pays 102% Medicare OPPS,18000,90,,,percent of total billed charges,90% of total billed charges,7000,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13740,68.7,,,percent of total billed charges,68.7% of total billed charges,16000,80,,,percent of total billed charges,80 percent of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4090.85,90,,,fee schedule,Pays 90% Medicare OPPS,11600,58,,,percent of total billed charges,58% of total billed charges,4074,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4584.49,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,17000,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,18000,
"Removal of lesions of the ovary, pelvic viscera, or peritoneal surface",1558662,CDM,360,RC,58662,HCPCS,Outpatient,,,20000,16000,,17000,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,4074,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,4636.3,102,,,fee schedule,Pays 102% Medicare OPPS,18000,90,,,percent of total billed charges,90% of total billed charges,7000,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,13740,68.7,,,percent of total billed charges,68.7% of total billed charges,16000,80,,,percent of total billed charges,80 percent of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4090.85,90,,,fee schedule,Pays 90% Medicare OPPS,11600,58,,,percent of total billed charges,58% of total billed charges,4074,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4584.49,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,17000,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,18000,
Surgery to remove of all or part of a torn meniscus in both medial and lateral compartments,1529880,CDM,360,RC,29880,HCPCS,Outpatient,,,20625,16500,,17531.25,85,,,percent of total billed charges,85% of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,3403.66,130,,,fee schedule,Pays 130% Medicare OPPS,4201.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2594.86,102,,,fee schedule,Pays 102% Medicare OPPS,18562.5,90,,,percent of total billed charges,90% of total billed charges,7218.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,14169.38,68.7,,,percent of total billed charges,68.7% of total billed charges,16500,80,,,percent of total billed charges,80 percent of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2289.59,90,,,fee schedule,Pays 90% Medicare OPPS,11962.5,58,,,percent of total billed charges,58% of total billed charges,4201.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2618.21,100,,,fee schedule,Pays 100% Medicare OPPS,3403.66,130,,,fee schedule,Pays 130% Medicare OPPS,17531.25,85,,,percent of total billed charges,85% of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,18562.5,
Surgery to remove of all or part of a torn meniscus in one compartment,1529881,CDM,360,RC,29881,HCPCS,Outpatient,,,20625,16500,,17531.25,85,,,percent of total billed charges,85% of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,3403.66,130,,,fee schedule,Pays 130% Medicare OPPS,4201.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2594.86,102,,,fee schedule,Pays 102% Medicare OPPS,18562.5,90,,,percent of total billed charges,90% of total billed charges,7218.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,14169.38,68.7,,,percent of total billed charges,68.7% of total billed charges,16500,80,,,percent of total billed charges,80 percent of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2289.59,90,,,fee schedule,Pays 90% Medicare OPPS,11962.5,58,,,percent of total billed charges,58% of total billed charges,4201.31,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2618.21,100,,,fee schedule,Pays 100% Medicare OPPS,3403.66,130,,,fee schedule,Pays 130% Medicare OPPS,17531.25,85,,,percent of total billed charges,85% of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,18562.5,
LAP ING HERNIA REPAIR RECUR,1549651,CDM,360,RC,49651,HCPCS,Outpatient,,,21190,16952,,18011.5,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare ,4316.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,4636.3,102,,,fee schedule,Pays 102% Medicare OPPS,19071,90,,,percent of total billed charges,90% of total billed charges,7416.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,14557.53,68.7,,,percent of total billed charges,68.7% of total billed charges,16952,80,,,percent of total billed charges,80 percent of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4090.85,90,,,fee schedule,Pays 90% Medicare OPPS,12290.2,58,,,percent of total billed charges,58% of total billed charges,4316.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4584.49,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare ,18011.5,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,19071,
Gallbladder removal with use of an x-ray exam of the bile ducts,1547563,CDM,360,RC,47563,HCPCS,Outpatient,,,21250,17000,,18062.5,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,4328.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,4636.3,102,,,fee schedule,Pays 102% Medicare OPPS,19125,90,,,percent of total billed charges,90% of total billed charges,7437.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,14598.75,68.7,,,percent of total billed charges,68.7% of total billed charges,17000,80,,,percent of total billed charges,80 percent of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4090.85,90,,,fee schedule,Pays 90% Medicare OPPS,12325,58,,,percent of total billed charges,58% of total billed charges,4328.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4584.49,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,18062.5,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,19125,
STROKE KIT,2600166,CDM,636,RC,J2590,HCPCS,Both,,,21275,17020,,18083.75,85,,,percent of total billed charges,85% of total billed charges,5318.75,100,,,fee schedule,Pays 100% Medicare ,5318.75,100,,,fee schedule,Pays 100% Medicare ,5318.75,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,4333.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,11099.38,52.17,,,case rate,100% of BCBS case rate,11099.38,52.17,,,case rate,100% of BCBS case rate,11099.38,52.17,,,case rate,100% of BCBS case rate,11099.38,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,19147.5,90,,,percent of total billed charges,90% of total billed charges,7446.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,14615.93,68.7,,,percent of total billed charges,68.7% of total billed charges,17020,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,19147.5,90,,,fee schedule,Pays 90% Medicare ,12339.5,58,,,percent of total billed charges,58% of total billed charges,4333.72,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18083.75,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,4333.72,19147.5,
ARTHROSC KNEE; W MEN REPAIR-MED/LAT,1529883,CDM,360,RC,29883,HCPCS,Outpatient,,,21520,17216,,18292,85,,,percent of total billed charges,85% of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,3403.66,130,,,fee schedule,Pays 130% Medicare OPPS,4383.62,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,2594.86,102,,,fee schedule,Pays 102% Medicare OPPS,19368,90,,,percent of total billed charges,90% of total billed charges,7532,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,14784.24,68.7,,,percent of total billed charges,68.7% of total billed charges,17216,80,,,percent of total billed charges,80 percent of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,2289.59,90,,,fee schedule,Pays 90% Medicare OPPS,12481.6,58,,,percent of total billed charges,58% of total billed charges,4383.62,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2618.21,100,,,fee schedule,Pays 100% Medicare OPPS,3403.66,130,,,fee schedule,Pays 130% Medicare OPPS,18292,85,,,percent of total billed charges,85% of total billed charges,2543.98,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,19368,
LAP VENT/ABD HERNIA REPAIR,1549652,CDM,360,RC,49652,HCPCS,Outpatient,,,21565,17252,,18330.25,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4392.79,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,4636.3,102,,,fee schedule,Pays 102% Medicare OPPS,19408.5,90,,,percent of total billed charges,90% of total billed charges,7547.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,14815.16,68.7,,,percent of total billed charges,68.7% of total billed charges,17252,80,,,percent of total billed charges,80 percent of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4090.85,90,,,fee schedule,Pays 90% Medicare OPPS,12507.7,58,,,percent of total billed charges,58% of total billed charges,4392.79,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18330.25,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,19408.5,
UNLISTED LAPAROSCOPY ESOPHAGUS,1543289,CDM,360,RC,43289,HCPCS,Outpatient,,,21875,17500,,18593.75,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,4455.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,4636.3,102,,,fee schedule,Pays 102% Medicare OPPS,19687.5,90,,,percent of total billed charges,90% of total billed charges,7656.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,15028.13,68.7,,,percent of total billed charges,68.7% of total billed charges,17500,80,,,percent of total billed charges,80 percent of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4090.85,90,,,fee schedule,Pays 90% Medicare OPPS,12687.5,58,,,percent of total billed charges,58% of total billed charges,4455.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4584.49,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,18593.75,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,19687.5,
LAP P COLECTOMY W REM ILEVM,1544205,CDM,360,RC,44205,HCPCS,Outpatient,,,21875,17500,,18593.75,85,,,percent of total billed charges,85% of total billed charges,21875,100,,,fee schedule,Pays 100% Medicare OPPS,21875,100,,,fee schedule,Pays 100% Medicare OPPS,21875,100,,,fee schedule,Pays 100% Medicare OPPS,21875,130,,,fee schedule,Pays 130% Medicare OPPS,4455.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,21875,102,,,fee schedule,Pays 102% Medicare OPPS,19687.5,90,,,percent of total billed charges,90% of total billed charges,7656.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,15028.13,68.7,,,percent of total billed charges,68.7% of total billed charges,17500,80,,,percent of total billed charges,80 percent of total billed charges,21875,100,,,fee schedule,Pays 100% Medicare OPPS,21875,90,,,fee schedule,Pays 90% Medicare OPPS,12687.5,58,,,percent of total billed charges,58% of total billed charges,4455.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,21875,100,,,fee schedule,Pays 100% Medicare OPPS,21875,130,,,fee schedule,Pays 130% Medicare OPPS,18593.75,85,,,percent of total billed charges,85% of total billed charges,21875,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,21875,
L COLECTOMY/COLECTMY PRTL W COLOSTOMY,1544208,CDM,360,RC,44208,HCPCS,Outpatient,,,21875,17500,,18593.75,85,,,percent of total billed charges,85% of total billed charges,21875,100,,,fee schedule,Pays 100% Medicare OPPS,21875,100,,,fee schedule,Pays 100% Medicare OPPS,21875,100,,,fee schedule,Pays 100% Medicare OPPS,21875,130,APC,,fee schedule,Pays 130% Medicare OPPS,4455.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,21875,102,,,fee schedule,Pays 102% Medicare OPPS,19687.5,90,,,percent of total billed charges,90% of total billed charges,7656.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,15028.13,68.7,,,percent of total billed charges,68.7% of total billed charges,17500,80,,,percent of total billed charges,80 percent of total billed charges,21875,100,,,fee schedule,Pays 100% Medicare OPPS,21875,90,,,fee schedule,Pays 90% Medicare OPPS,12687.5,58,,,percent of total billed charges,58% of total billed charges,4455.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,21875,100,,,fee schedule,Pays 100% Medicare OPPS,21875,130,APC,,fee schedule,Pays 130% Medicare OPPS,18593.75,85,,,percent of total billed charges,85% of total billed charges,21875,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,21875,
APPY; FOR RUPT APPENDIX W PERITONITIS,1544960,CDM,360,RC,44960,HCPCS,Outpatient,,,21875,17500,,18593.75,85,,,percent of total billed charges,85% of total billed charges,21875,100,,,fee schedule,Pays 100% Medicare OPPS,21875,100,,,fee schedule,Pays 100% Medicare OPPS,21875,100,,,fee schedule,Pays 100% Medicare OPPS,21875,130,APC,,fee schedule,Pays 130% Medicare OPPS,4455.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,21875,102,,,fee schedule,Pays 102% Medicare OPPS,19687.5,90,,,percent of total billed charges,90% of total billed charges,7656.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,15028.13,68.7,,,percent of total billed charges,68.7% of total billed charges,17500,80,,,percent of total billed charges,80 percent of total billed charges,21875,100,,,fee schedule,Pays 100% Medicare OPPS,21875,90,,,fee schedule,Pays 90% Medicare OPPS,12687.5,58,,,percent of total billed charges,58% of total billed charges,4455.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,21875,100,,,fee schedule,Pays 100% Medicare OPPS,21875,130,APC,,fee schedule,Pays 130% Medicare OPPS,18593.75,85,,,percent of total billed charges,85% of total billed charges,21875,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,21875,
LAPAROSCOPY APPENDECTOMY,1544970,CDM,360,RC,44970,HCPCS,Outpatient,,,21875,17500,,18593.75,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,4455.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,4636.3,102,,,fee schedule,Pays 102% Medicare OPPS,19687.5,90,,,percent of total billed charges,90% of total billed charges,7656.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,15028.13,68.7,,,percent of total billed charges,68.7% of total billed charges,17500,80,,,percent of total billed charges,80 percent of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4090.85,90,,,fee schedule,Pays 90% Medicare OPPS,12687.5,58,,,percent of total billed charges,58% of total billed charges,4455.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4584.49,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,18593.75,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,19687.5,
LAP; DX ABDOMEN PERRITONEUM OMENTUM,1549320,CDM,360,RC,49320,HCPCS,Outpatient,,,21875,17500,,18593.75,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,4455.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,4636.3,102,,,fee schedule,Pays 102% Medicare OPPS,19687.5,90,,,percent of total billed charges,90% of total billed charges,7656.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,15028.13,68.7,,,percent of total billed charges,68.7% of total billed charges,17500,80,,,percent of total billed charges,80 percent of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4090.85,90,,,fee schedule,Pays 90% Medicare OPPS,12687.5,58,,,percent of total billed charges,58% of total billed charges,4455.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4584.49,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,18593.75,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,19687.5,
LAP; ABD PERIT OMENTUM W ASP CYST,1549322,CDM,360,RC,49322,HCPCS,Outpatient,,,21875,17500,,18593.75,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,4455.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,4636.3,102,,,fee schedule,Pays 102% Medicare OPPS,19687.5,90,,,percent of total billed charges,90% of total billed charges,7656.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,15028.13,68.7,,,percent of total billed charges,68.7% of total billed charges,17500,80,,,percent of total billed charges,80 percent of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4090.85,90,,,fee schedule,Pays 90% Medicare OPPS,12687.5,58,,,percent of total billed charges,58% of total billed charges,4455.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4584.49,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,18593.75,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,19687.5,
Inguinal hernia repair done by laparoscope,1549650,CDM,360,RC,49650,HCPCS,Outpatient,,,21875,17500,,18593.75,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,4455.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,4636.3,102,,,fee schedule,Pays 102% Medicare OPPS,19687.5,90,,,percent of total billed charges,90% of total billed charges,7656.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,15028.13,68.7,,,percent of total billed charges,68.7% of total billed charges,17500,80,,,percent of total billed charges,80 percent of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4090.85,90,,,fee schedule,Pays 90% Medicare OPPS,12687.5,58,,,percent of total billed charges,58% of total billed charges,4455.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4584.49,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,18593.75,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,19687.5,
LAP ING HERNIA REPAIR INIT,1549654,CDM,360,RC,49654,HCPCS,Outpatient,,,21875,17500,,18593.75,85,,,percent of total billed charges,85% of total billed charges,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4455.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,8161.07,102,,,fee schedule,Pays 102% Medicare OPPS,19687.5,90,,,percent of total billed charges,90% of total billed charges,7656.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,15028.13,68.7,,,percent of total billed charges,68.7% of total billed charges,17500,80,,,percent of total billed charges,80 percent of total billed charges,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,7200.95,90,,,fee schedule,Pays 90% Medicare OPPS,12687.5,58,,,percent of total billed charges,58% of total billed charges,4455.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18593.75,85,,,percent of total billed charges,85% of total billed charges,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,19687.5,
LAPAROSCOPY; W LYSIS OF ADHESIONS,1558660,CDM,360,RC,58660,HCPCS,Outpatient,,,21875,17500,,18593.75,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,4455.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,4636.3,102,,,fee schedule,Pays 102% Medicare OPPS,19687.5,90,,,percent of total billed charges,90% of total billed charges,7656.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,15028.13,68.7,,,percent of total billed charges,68.7% of total billed charges,17500,80,,,percent of total billed charges,80 percent of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4090.85,90,,,fee schedule,Pays 90% Medicare OPPS,12687.5,58,,,percent of total billed charges,58% of total billed charges,4455.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4584.49,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,18593.75,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,19687.5,
THYROIDECTOMY TOTAL,1560240,CDM,360,RC,60240,HCPCS,Outpatient,,,21875,17500,,18593.75,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,4455.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,4636.3,102,,,fee schedule,Pays 102% Medicare OPPS,19687.5,90,,,percent of total billed charges,90% of total billed charges,7656.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,15028.13,68.7,,,percent of total billed charges,68.7% of total billed charges,17500,80,,,percent of total billed charges,80 percent of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4090.85,90,,,fee schedule,Pays 90% Medicare OPPS,12687.5,58,,,percent of total billed charges,58% of total billed charges,4455.94,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4584.49,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,18593.75,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,19687.5,
UNLISTED LAPAROSCOPY ABD PERIT OMENT,1549329,CDM,360,RC,49329,HCPCS,Outpatient,,,22160,17728,,18836,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,4513.99,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,4636.3,102,,,fee schedule,Pays 102% Medicare OPPS,19944,90,,,percent of total billed charges,90% of total billed charges,7756,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,15223.92,68.7,,,percent of total billed charges,68.7% of total billed charges,17728,80,,,percent of total billed charges,80 percent of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4090.85,90,,,fee schedule,Pays 90% Medicare OPPS,12852.8,58,,,percent of total billed charges,58% of total billed charges,4513.99,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4584.49,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,18836,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,19944,
LAP VENT/ABD HERN PROC COMP,1549653,CDM,360,RC,49653,HCPCS,Outpatient,,,22190,17752,,18861.5,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4520.1,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,4636.3,102,,,fee schedule,Pays 102% Medicare OPPS,19971,90,,,percent of total billed charges,90% of total billed charges,7766.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,15244.53,68.7,,,percent of total billed charges,68.7% of total billed charges,17752,80,,,percent of total billed charges,80 percent of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4090.85,90,,,fee schedule,Pays 90% Medicare OPPS,12870.2,58,,,percent of total billed charges,58% of total billed charges,4520.1,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,18861.5,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,19971,
TOTAL THYROID LOBECTOMY UNILATERAL,1560220,CDM,360,RC,60220,HCPCS,Outpatient,,,22190,17752,,18861.5,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,4520.1,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,4636.3,102,,,fee schedule,Pays 102% Medicare OPPS,19971,90,,,percent of total billed charges,90% of total billed charges,7766.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,15244.53,68.7,,,percent of total billed charges,68.7% of total billed charges,17752,80,,,percent of total billed charges,80 percent of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4090.85,90,,,fee schedule,Pays 90% Medicare OPPS,12870.2,58,,,percent of total billed charges,58% of total billed charges,4520.1,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4584.49,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,18861.5,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,19971,
TOTAL THYROIDLOBECTOMY; W CSL,1560225,CDM,360,RC,60225,HCPCS,Outpatient,,,22190,17752,,18861.5,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,4520.1,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,4636.3,102,,,fee schedule,Pays 102% Medicare OPPS,19971,90,,,percent of total billed charges,90% of total billed charges,7766.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,15244.53,68.7,,,percent of total billed charges,68.7% of total billed charges,17752,80,,,percent of total billed charges,80 percent of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4090.85,90,,,fee schedule,Pays 90% Medicare OPPS,12870.2,58,,,percent of total billed charges,58% of total billed charges,4520.1,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4584.49,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare OPPS,18861.5,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,19971,
MASTOPEXY,1519316,CDM,360,RC,19316,HCPCS,Outpatient,,,22225,17780,,18891.25,85,,,percent of total billed charges,85% of total billed charges,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,6795.71,130,,,fee schedule,Pays 130% Medicare OPPS,4527.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,5070.89,102,,,fee schedule,Pays 102% Medicare OPPS,20002.5,90,,,percent of total billed charges,90% of total billed charges,7778.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,15268.58,68.7,,,percent of total billed charges,68.7% of total billed charges,17780,80,,,percent of total billed charges,80 percent of total billed charges,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,4474.32,90,,,fee schedule,Pays 90% Medicare OPPS,12890.5,58,,,percent of total billed charges,58% of total billed charges,4527.23,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5227.47,100,,,fee schedule,Pays 100% Medicare OPPS,6795.71,130,,,fee schedule,Pays 130% Medicare OPPS,18891.25,85,,,percent of total billed charges,85% of total billed charges,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,20002.5,
MAST MOD RAD,1519307,CDM,360,RC,19307,HCPCS,Outpatient,,,22940,18352,,19499,85,,,percent of total billed charges,85% of total billed charges,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,6795.71,130,,,fee schedule,Pays 130% Medicare OPPS,4672.88,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,5070.89,102,,,fee schedule,Pays 102% Medicare OPPS,20646,90,,,percent of total billed charges,90% of total billed charges,8029,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,15759.78,68.7,,,percent of total billed charges,68.7% of total billed charges,18352,80,,,percent of total billed charges,80 percent of total billed charges,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,4474.32,90,,,fee schedule,Pays 90% Medicare OPPS,13305.2,58,,,percent of total billed charges,58% of total billed charges,4672.88,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5227.47,100,,,fee schedule,Pays 100% Medicare OPPS,6795.71,130,,,fee schedule,Pays 130% Medicare OPPS,19499,85,,,percent of total billed charges,85% of total billed charges,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,20646,
BREAST MAMMAPLASTY,1519318,CDM,360,RC,19318,HCPCS,Outpatient,,,23125,18500,,19656.25,85,,,percent of total billed charges,85% of total billed charges,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,6795.71,130,,,fee schedule,Pays 130% Medicare OPPS,4710.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,5070.89,102,,,fee schedule,Pays 102% Medicare OPPS,20812.5,90,,,percent of total billed charges,90% of total billed charges,8093.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,15886.88,68.7,,,percent of total billed charges,68.7% of total billed charges,18500,80,,,percent of total billed charges,80 percent of total billed charges,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,4474.32,90,,,fee schedule,Pays 90% Medicare OPPS,13412.5,58,,,percent of total billed charges,58% of total billed charges,4710.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5227.47,100,,,fee schedule,Pays 100% Medicare OPPS,6795.71,130,,,fee schedule,Pays 130% Medicare OPPS,19656.25,85,,,percent of total billed charges,85% of total billed charges,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,20812.5,
BREAST RECONSTRUCT W OTHR,1519366,CDM,360,RC,19366,HCPCS,Outpatient,,,23125,18500,,19656.25,85,,,percent of total billed charges,85% of total billed charges,5781.25,100,,,fee schedule,Pays 100% Medicare OPPS,5781.25,100,,,fee schedule,Pays 100% Medicare OPPS,5781.25,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,4710.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,,,,,other,Not reimbursable per contract,20812.5,90,,,percent of total billed charges,90% of total billed charges,8093.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,15886.88,68.7,,,percent of total billed charges,68.7% of total billed charges,18500,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,20812.5,90,,,fee schedule,Pays 90% Medicare OPPS,13412.5,58,,,percent of total billed charges,58% of total billed charges,4710.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,19656.25,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,862.48,20812.5,
REVISION RECONSTRUCTED BREAST,1519380,CDM,360,RC,19380,HCPCS,Outpatient,,,23125,18500,,19656.25,85,,,percent of total billed charges,85% of total billed charges,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,6795.71,130,,,fee schedule,Pays 130% Medicare OPPS,4710.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,5070.89,102,,,fee schedule,Pays 102% Medicare OPPS,20812.5,90,,,percent of total billed charges,90% of total billed charges,8093.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,15886.88,68.7,,,percent of total billed charges,68.7% of total billed charges,18500,80,,,percent of total billed charges,80 percent of total billed charges,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,4474.32,90,,,fee schedule,Pays 90% Medicare OPPS,13412.5,58,,,percent of total billed charges,58% of total billed charges,4710.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5227.47,100,,,fee schedule,Pays 100% Medicare OPPS,6795.71,130,,,fee schedule,Pays 130% Medicare OPPS,19656.25,85,,,percent of total billed charges,85% of total billed charges,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,20812.5,
EXCISION OF SUBMANDIBULARGLAND,1542440,CDM,360,RC,42440,HCPCS,Outpatient,,,23125,18500,,19656.25,85,,,percent of total billed charges,85% of total billed charges,4568.77,100,,,fee schedule,Pays 100% Medicare OPPS,4568.77,100,,,fee schedule,Pays 100% Medicare OPPS,4568.77,100,,,fee schedule,Pays 100% Medicare OPPS,6105.66,130,,,fee schedule,Pays 130% Medicare OPPS,4710.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,4660.14,102,,,fee schedule,Pays 102% Medicare OPPS,20812.5,90,,,percent of total billed charges,90% of total billed charges,8093.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,15886.88,68.7,,,percent of total billed charges,68.7% of total billed charges,18500,80,,,percent of total billed charges,80 percent of total billed charges,4568.77,100,,,fee schedule,Pays 100% Medicare OPPS,4111.89,90,,,fee schedule,Pays 90% Medicare OPPS,13412.5,58,,,percent of total billed charges,58% of total billed charges,4710.56,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4696.66,100,,,fee schedule,Pays 100% Medicare OPPS,6105.66,130,,,fee schedule,Pays 130% Medicare OPPS,19656.25,85,,,percent of total billed charges,85% of total billed charges,4568.77,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,20812.5,
MASTECTOMY PARTIAL W/LN REMOVAL,1519302,CDM,360,RC,19302,HCPCS,Outpatient,,,24190,19352,,20561.5,85,,,percent of total billed charges,85% of total billed charges,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,6795.71,130,,,fee schedule,Pays 130% Medicare OPPS,4927.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,5070.89,102,,,fee schedule,Pays 102% Medicare OPPS,21771,90,,,percent of total billed charges,90% of total billed charges,8466.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,16618.53,68.7,,,percent of total billed charges,68.7% of total billed charges,19352,80,,,percent of total billed charges,80 percent of total billed charges,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,4474.32,90,,,fee schedule,Pays 90% Medicare OPPS,14030.2,58,,,percent of total billed charges,58% of total billed charges,4927.5,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5227.47,100,,,fee schedule,Pays 100% Medicare OPPS,6795.71,130,,,fee schedule,Pays 130% Medicare OPPS,20561.5,85,,,percent of total billed charges,85% of total billed charges,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,21771,
MASTECTOMY SIMPLE COMPLETE,1519303,CDM,360,RC,19303,HCPCS,Outpatient,,,24250,19400,,20612.5,85,,,percent of total billed charges,85% of total billed charges,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,6795.71,130,,,fee schedule,Pays 130% Medicare OPPS,4939.73,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,5070.89,102,,,fee schedule,Pays 102% Medicare OPPS,21825,90,,,percent of total billed charges,90% of total billed charges,8487.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,16659.75,68.7,,,percent of total billed charges,68.7% of total billed charges,19400,80,,,percent of total billed charges,80 percent of total billed charges,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,4474.32,90,,,fee schedule,Pays 90% Medicare OPPS,14065,58,,,percent of total billed charges,58% of total billed charges,4939.73,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5227.47,100,,,fee schedule,Pays 100% Medicare OPPS,6795.71,130,,,fee schedule,Pays 130% Medicare OPPS,20612.5,85,,,percent of total billed charges,85% of total billed charges,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,21825,
INSJ BREAST IMPLT SM D MAST,1519340,CDM,360,RC,19340,HCPCS,Outpatient,,,24250,19400,,20612.5,85,,,percent of total billed charges,85% of total billed charges,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,6795.71,130,,,fee schedule,Pays 130% Medicare OPPS,4939.73,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,5070.89,102,,,fee schedule,Pays 102% Medicare OPPS,21825,90,,,percent of total billed charges,90% of total billed charges,8487.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,16659.75,68.7,,,percent of total billed charges,68.7% of total billed charges,19400,80,,,percent of total billed charges,80 percent of total billed charges,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,4474.32,90,,,fee schedule,Pays 90% Medicare OPPS,14065,58,,,percent of total billed charges,58% of total billed charges,4939.73,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5227.47,100,,,fee schedule,Pays 100% Medicare OPPS,6795.71,130,,,fee schedule,Pays 130% Medicare OPPS,20612.5,85,,,percent of total billed charges,85% of total billed charges,4971.47,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,21825,
Removal of gallbladder using an endoscope,1547562,CDM,360,RC,47562,HCPCS,Outpatient,,,24375,19500,,20718.75,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare ,4965.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,4636.3,102,,,fee schedule,Pays 102% Medicare OPPS,21937.5,90,,,percent of total billed charges,90% of total billed charges,8531.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,16745.63,68.7,,,percent of total billed charges,68.7% of total billed charges,19500,80,,,percent of total billed charges,80 percent of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,4090.85,90,,,fee schedule,Pays 90% Medicare OPPS,14137.5,58,,,percent of total billed charges,58% of total billed charges,4965.19,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,4584.49,100,,,fee schedule,Pays 100% Medicare OPPS,5959.85,130,,,fee schedule,Pays 130% Medicare ,20718.75,85,,,percent of total billed charges,85% of total billed charges,4545.38,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,21937.5,
Surgical procedures on the kidney to break up and remove kidney stones,1550590,CDM,790,RC,50590,HCPCS,Outpatient,,,25445,20356,,21628.25,85,,,percent of total billed charges,85% of total billed charges,2761.91,100,,,fee schedule,Pays 100% Medicare OPPS,2761.91,100,,,fee schedule,Pays 100% Medicare OPPS,2761.91,100,,,fee schedule,Pays 100% Medicare OPPS,3664.9,130,,,fee schedule,Pays 130% Medicare ,5183.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2000,100,,,percent of total billed charges,56.5 percent of total billed charges,2817.15,102,,,fee schedule,Pays 102% Medicare OPPS,22900.5,90,,,percent of total billed charges,90% of total billed charges,8905.75,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,17480.72,68.7,,,percent of total billed charges,68.7% of total billed charges,20356,80,,,percent of total billed charges,80 percent of total billed charges,2761.91,100,,,fee schedule,Pays 100% Medicare OPPS,2485.71,90,,,fee schedule,Pays 90% Medicare OPPS,14758.1,58,,,percent of total billed charges,58% of total billed charges,5183.15,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,2819.15,100,,,fee schedule,Pays 100% Medicare OPPS,3664.9,130,,,fee schedule,Pays 130% Medicare ,21628.25,85,,,percent of total billed charges,85% of total billed charges,2761.91,100,,,fee schedule,Pays 100% Medicare OPPS,2000,22900.5,
CORTIVA 1MM ALLOGRAFT DERMIS 16 X 20CM,1570395,CDM,278,RC,Q4100,HCPCS,Both,,,27120,21696,,23052,85,,,percent of total billed charges,85% of total billed charges,6780,100,,,fee schedule,Pays 100% Medicare ,6780,100,,,fee schedule,Pays 100% Medicare ,6780,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,5524.34,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14148.78,52.17,,,case rate,100% of BCBS case rate,14148.78,52.17,,,case rate,100% of BCBS case rate,14148.78,52.17,,,case rate,100% of BCBS case rate,14148.78,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,24408,90,,,percent of total billed charges,90% of total billed charges,9492,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,18631.44,68.7,,,percent of total billed charges,68.7% of total billed charges,21696,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,24408,90,,,fee schedule,Pays 90% Medicare ,15729.6,58,,,percent of total billed charges,58% of total billed charges,5524.34,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,23052,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,5524.34,24408,
HERNIA MESH PHASIX ST 1201520,1570389,CDM,278,RC,C1781,HCPCS,Both,,,31250,25000,,26562.5,85,,,percent of total billed charges,85% of total billed charges,7812.5,100,,,fee schedule,Pays 100% Medicare ,7812.5,100,,,fee schedule,Pays 100% Medicare ,7812.5,100,,,fee schedule,Pays 100% Medicare ,,,,,other,Not reimbursable per contract,6365.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,16303.44,52.17,,,case rate,100% of BCBS case rate,16303.44,52.17,,,case rate,100% of BCBS case rate,16303.44,52.17,,,case rate,100% of BCBS case rate,16303.44,52.17,,,case rate,100% of BCBS case rate,,,,,other,Not reimbursable per contract,28125,90,,,percent of total billed charges,90% of total billed charges,10937.5,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,21468.75,68.7,,,percent of total billed charges,68.7% of total billed charges,25000,80,,,percent of total billed charges,80 percent of total billed charges,,,,,other,Not reimbursable per contract,28125,90,,,fee schedule,Pays 90% Medicare ,18125,58,,,percent of total billed charges,58% of total billed charges,6365.63,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,26562.5,85,,,percent of total billed charges,85% of total billed charges,,,,,other,Not reimbursable per contract,6365.63,28125,
SURGICAL ARTHROSCOPY SHOLDER W/ROTATOR,1529827,CDM,360,RC,29827,HCPCS,Outpatient,,,32000,25600,,27200,85,,,percent of total billed charges,85% of total billed charges,5626.71,100,,,fee schedule,Pays 100% Medicare OPPS,5626.71,100,,,fee schedule,Pays 100% Medicare OPPS,5626.71,100,,,fee schedule,Pays 100% Medicare OPPS,7563.51,130,,,fee schedule,Pays 130% Medicare OPPS,6518.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,5739.25,102,,,fee schedule,Pays 102% Medicare OPPS,28800,90,,,percent of total billed charges,90% of total billed charges,11200,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,21984,68.7,,,percent of total billed charges,68.7% of total billed charges,25600,80,,,percent of total billed charges,80 percent of total billed charges,5626.71,100,,,fee schedule,Pays 100% Medicare OPPS,5064.04,90,,,fee schedule,Pays 90% Medicare OPPS,18560,58,,,percent of total billed charges,58% of total billed charges,6518.4,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,5818.09,100,,,fee schedule,Pays 100% Medicare OPPS,7563.51,130,,,fee schedule,Pays 130% Medicare OPPS,27200,85,,,percent of total billed charges,85% of total billed charges,5626.71,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,28800,
LAPS RPR PARAESOPH HER RPR W/MESH,1543282,CDM,360,RC,43282,HCPCS,Outpatient,,,35315,28252,,30017.75,85,,,percent of total billed charges,85% of total billed charges,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,10390.91,130,,,fee schedule,Pays 130% Medicare OPPS,7193.67,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,8161.07,102,,,fee schedule,Pays 102% Medicare OPPS,31783.5,90,,,percent of total billed charges,90% of total billed charges,12360.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,24261.41,68.7,,,percent of total billed charges,68.7% of total billed charges,28252,80,,,percent of total billed charges,80 percent of total billed charges,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,7200.95,90,,,fee schedule,Pays 90% Medicare OPPS,20482.7,58,,,percent of total billed charges,58% of total billed charges,7193.67,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,7992.99,100,,,fee schedule,Pays 100% Medicare OPPS,10390.91,130,,,fee schedule,Pays 130% Medicare OPPS,30017.75,85,,,percent of total billed charges,85% of total billed charges,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,31783.5,
LAPS ESOPHAGOGASTRIC FUNDOPLASTY,1543280,CDM,360,RC,43280,HCPCS,Outpatient,,,36875,29500,,31343.75,85,,,percent of total billed charges,85% of total billed charges,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,10390.91,130,,,fee schedule,Pays 130% Medicare OPPS,7511.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,8161.07,102,,,fee schedule,Pays 102% Medicare OPPS,33187.5,90,,,percent of total billed charges,90% of total billed charges,12906.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,25333.13,68.7,,,percent of total billed charges,68.7% of total billed charges,29500,80,,,percent of total billed charges,80 percent of total billed charges,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,7200.95,90,,,fee schedule,Pays 90% Medicare OPPS,21387.5,58,,,percent of total billed charges,58% of total billed charges,7511.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,7992.99,100,,,fee schedule,Pays 100% Medicare OPPS,10390.91,130,,,fee schedule,Pays 130% Medicare OPPS,31343.75,85,,,percent of total billed charges,85% of total billed charges,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,33187.5,
LAP INC HERN REPAIR COMP,1549655,CDM,360,RC,49655,HCPCS,Outpatient,,,36875,29500,,31343.75,85,,,percent of total billed charges,85% of total billed charges,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7511.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,8161.07,102,,,fee schedule,Pays 102% Medicare OPPS,33187.5,90,,,percent of total billed charges,90% of total billed charges,12906.25,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,25333.13,68.7,,,percent of total billed charges,68.7% of total billed charges,29500,80,,,percent of total billed charges,80 percent of total billed charges,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,7200.95,90,,,fee schedule,Pays 90% Medicare OPPS,21387.5,58,,,percent of total billed charges,58% of total billed charges,7511.44,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,31343.75,85,,,percent of total billed charges,85% of total billed charges,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,33187.5,
LAP INC HERNIA REPAIR RECUR,1549656,CDM,360,RC,49656,HCPCS,Outpatient,,,39020,31216,,33167,85,,,percent of total billed charges,85% of total billed charges,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7948.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,8161.07,102,,,fee schedule,Pays 102% Medicare OPPS,35118,90,,,percent of total billed charges,90% of total billed charges,13657,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,26806.74,68.7,,,percent of total billed charges,68.7% of total billed charges,31216,80,,,percent of total billed charges,80 percent of total billed charges,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,7200.95,90,,,fee schedule,Pays 90% Medicare OPPS,22631.6,58,,,percent of total billed charges,58% of total billed charges,7948.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33167,85,,,percent of total billed charges,85% of total billed charges,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,35118,
LAP INC HERN RECUR COMP,1549657,CDM,360,RC,49657,HCPCS,Outpatient,,,39020,31216,,33167,85,,,percent of total billed charges,85% of total billed charges,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,,,,,other,Not reimbursable per contract,7948.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,8161.07,102,,,fee schedule,Pays 102% Medicare OPPS,35118,90,,,percent of total billed charges,90% of total billed charges,13657,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,26806.74,68.7,,,percent of total billed charges,68.7% of total billed charges,31216,80,,,percent of total billed charges,80 percent of total billed charges,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,7200.95,90,,,fee schedule,Pays 90% Medicare OPPS,22631.6,58,,,percent of total billed charges,58% of total billed charges,7948.37,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,,,,,other,Not reimbursable per contract,,,,,other,Not reimbursable per contract,33167,85,,,percent of total billed charges,85% of total billed charges,8001.05,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,35118,
TISS XPNDR BRST RECNSTJ,1519357,CDM,360,RC,19357,HCPCS,Outpatient,,,65440,52352,,55624,85,,,percent of total billed charges,85% of total billed charges,13402.79,100,,,fee schedule,Pays 100% Medicare OPPS,13402.79,100,,,fee schedule,Pays 100% Medicare OPPS,13402.79,100,,,fee schedule,Pays 100% Medicare OPPS,19077.12,130,,,fee schedule,Pays 130% Medicare ,13330.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,862.48,100,,,fee schedule,100% of ASC Unlisted Rate,986.63,100,,,fee schedule,100% of ASC Unlisted Rate,13670.84,102,,,fee schedule,Pays 102% Medicare OPPS,58896,90,,,percent of total billed charges,90% of total billed charges,22904,35,,,percent of total billed charges,35% based on GA Medicaid OP CCR Rate,44957.28,68.7,,,percent of total billed charges,68.7% of total billed charges,52352,80,,,percent of total billed charges,80 percent of total billed charges,13402.79,100,,,fee schedule,Pays 100% Medicare OPPS,12062.5,90,,,fee schedule,Pays 90% Medicare OPPS,37955.2,58,,,percent of total billed charges,58% of total billed charges,13330.13,20.37,,,percent of total billed charges,20.37% based on GA Medicaid OP CCR Rate,14674.71,100,,,fee schedule,Pays 100% Medicare OPPS,19077.12,130,,,fee schedule,Pays 130% Medicare ,55624,85,,,percent of total billed charges,85% of total billed charges,13402.79,100,,,fee schedule,Pays 100% Medicare OPPS,862.48,58896,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,1,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,216438.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,216438.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,216438.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,281370.25,130,MS-DRG,,Case rate,130% Medicare MS-DRG,124921.15,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225096.2,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,129918.08,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,216438.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,205616.72,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,249842.31,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,216438.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,281370.25,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,216438.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,281370.25,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,2,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,98395.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,98395.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,98395.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,127913.85,130,MS-DRG,,Case rate,130% Medicare MS-DRG,84114.87,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102331.08,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,87479.52,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,98395.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,93475.51,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,168229.75,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,98395.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,127913.85,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,98395.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,168229.75,
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",3,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,170520.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,170520.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,170520.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,221676.74,130,MS-DRG,,Case rate,130% Medicare MS-DRG,124031.93,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177341.39,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,128993.29,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,170520.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,161994.54,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,248063.86,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,170520.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,221676.74,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,170520.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,248063.86,
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",4,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,117911.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,117911.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,117911.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,153284.85,130,MS-DRG,,Case rate,130% Medicare MS-DRG,89346.04,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122627.88,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,92919.95,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,117911.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,112015.85,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,178692.09,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,117911.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,153284.85,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,117911.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,178692.09,
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,5,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,83343.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,83343.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,83343.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,108346.6,130,MS-DRG,,Case rate,130% Medicare MS-DRG,185988.23,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86677.28,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,193427.88,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,83343.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,79176.36,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,371976.45,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,83343.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,108346.6,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,83343.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,371976.45,
LIVER TRANSPLANT WITHOUT MCC,6,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,39532.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39532.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39532.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,51392.78,130,MS-DRG,,Case rate,130% Medicare MS-DRG,84743.03,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41114.23,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,88132.8,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,39532.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37556.26,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,169486.05,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,39532.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,51392.78,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,39532.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,169486.05,
LUNG TRANSPLANT,7,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,98572.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,98572.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,98572.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,128144.24,130,MS-DRG,,Case rate,130% Medicare MS-DRG,60493.44,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102515.39,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,62913.21,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,98572.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,93643.87,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,120986.87,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,98572.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,128144.24,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,98572.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,128144.24,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,8,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,42908.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42908.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42908.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,55781.25,130,MS-DRG,,Case rate,130% Medicare MS-DRG,53707.94,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44625,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,55856.29,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,42908.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40763.22,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,107415.87,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,42908.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,55781.25,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,42908.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,107415.87,
PANCREAS TRANSPLANT,10,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,39347.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39347.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39347.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,51152.09,130,MS-DRG,,Case rate,130% Medicare MS-DRG,29737.59,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40921.67,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,30927.12,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,39347.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37380.37,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,59475.19,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,39347.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,51152.09,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,39347.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,59475.19,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",11,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,42071.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42071.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42071.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54692.39,130,MS-DRG,,Case rate,130% Medicare MS-DRG,26321.22,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43753.91,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,27374.09,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,42071.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39967.52,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,52642.44,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,42071.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54692.39,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,42071.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,54692.39,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",12,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,32921.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32921.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32921.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42797.7,130,MS-DRG,,Case rate,130% Medicare MS-DRG,25498.63,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34238.16,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,26518.59,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,32921.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31275.24,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,50997.25,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,32921.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42797.7,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,32921.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,50997.25,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",13,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,22438.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22438.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22438.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29169.53,130,MS-DRG,,Case rate,130% Medicare MS-DRG,12888.33,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23335.62,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13403.87,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,22438.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21316.2,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,25776.66,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,22438.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29169.53,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22438.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,29169.53,
ALLOGENEIC BONE MARROW TRANSPLANT,14,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,92171.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,92171.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,92171.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,119822.9,130,MS-DRG,,Case rate,130% Medicare MS-DRG,150262.29,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95858.32,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,156272.88,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,92171.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,87562.89,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,300524.57,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,92171.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,119822.9,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,92171.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,300524.57,
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,16,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,50182.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,50182.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,50182.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,65236.86,130,MS-DRG,,Case rate,130% Medicare MS-DRG,42994.21,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52189.49,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,44714.01,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,50182.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47673.09,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,85988.43,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,50182.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,65236.86,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,50182.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,85988.43,
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,17,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,50182.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,50182.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,50182.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,65236.86,130,MS-DRG,,Case rate,130% Medicare MS-DRG,19572.67,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52189.49,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20355.59,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,50182.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47673.09,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,39145.34,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,50182.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,65236.86,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,50182.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,65236.86,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,18,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,293871.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,293871.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,293871.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,382032.95,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305626.36,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,293871.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,279177.93,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,293871.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,382032.95,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,293871.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,382032.95,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,19,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,64617.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,64617.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,64617.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,84002.46,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67201.97,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,64617.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,61386.42,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,64617.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,84002.46,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,64617.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,84002.46,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,20,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,68264,100,MS-DRG,,Case rate,100% Medicare MS-DRG,68264,100,MS-DRG,,Case rate,100% Medicare MS-DRG,68264,100,MS-DRG,,Case rate,100% Medicare MS-DRG,88743.2,130,MS-DRG,,Case rate,130% Medicare MS-DRG,60060.33,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70994.56,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,62462.79,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,68264,100,MS-DRG,,Case rate,100% Medicare MS-DRG,64850.8,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,120120.66,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,68264,100,MS-DRG,,Case rate,100% Medicare MS-DRG,88743.2,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,68264,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,120120.66,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,21,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,49899.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49899.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49899.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,64869.1,130,MS-DRG,,Case rate,130% Medicare MS-DRG,37567.99,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51895.28,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,39070.74,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,49899.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47404.34,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,75135.99,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,49899.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,64869.1,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,49899.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,75135.99,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,22,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,32268.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32268.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32268.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41948.53,130,MS-DRG,,Case rate,130% Medicare MS-DRG,25786.96,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33558.82,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,26818.45,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,32268.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30654.7,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,51573.92,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,32268.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41948.53,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,32268.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,51573.92,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,23,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,46143.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46143.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46143.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,59986.85,130,MS-DRG,,Case rate,130% Medicare MS-DRG,35530.29,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47989.48,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,36951.52,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,46143.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43836.54,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,71060.57,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,46143.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,59986.85,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,46143.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,71060.57,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,24,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,31204.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31204.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31204.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40565.25,130,MS-DRG,,Case rate,130% Medicare MS-DRG,19472.72,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32452.2,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20251.65,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,31204.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29643.84,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,38945.45,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,31204.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40565.25,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,31204.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,40565.25,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,25,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,36188.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36188.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36188.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47044.65,130,MS-DRG,,Case rate,130% Medicare MS-DRG,30570.49,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37635.72,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,31793.33,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,36188.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34378.78,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,61140.97,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,36188.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47044.65,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,36188.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,61140.97,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,26,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,24563.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24563.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24563.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31931.95,130,MS-DRG,,Case rate,130% Medicare MS-DRG,20670.88,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25545.56,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21497.73,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,24563.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23334.89,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,41341.76,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,24563.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31931.95,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,24563.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,41341.76,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,27,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,20429.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20429.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20429.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26557.95,130,MS-DRG,,Case rate,130% Medicare MS-DRG,16106.63,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21246.36,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16750.9,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,20429.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19407.73,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,32213.25,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,20429.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26557.95,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20429.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,32213.25,
SPINAL PROCEDURES WITH MCC,28,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,48983.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,48983.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,48983.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,63677.98,130,MS-DRG,,Case rate,130% Medicare MS-DRG,30391.19,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50942.38,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,31606.85,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,48983.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46533.91,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,60782.37,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,48983.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,63677.98,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,48983.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,63677.98,
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,29,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,28338.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28338.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28338.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36840.02,130,MS-DRG,,Case rate,130% Medicare MS-DRG,18960.87,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29472.02,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,19719.32,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,28338.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26921.56,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,37921.75,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,28338.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36840.02,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,28338.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,37921.75,
SPINAL PROCEDURES WITHOUT CC/MCC,30,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,19524.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19524.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19524.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25381.28,130,MS-DRG,,Case rate,130% Medicare MS-DRG,12675.72,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20305.02,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13182.75,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,19524.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18547.86,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,25351.43,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,19524.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25381.28,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,19524.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,25381.28,
VENTRICULAR SHUNT PROCEDURES WITH MCC,31,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,33808.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33808.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33808.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43951.64,130,MS-DRG,,Case rate,130% Medicare MS-DRG,15274.95,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35161.31,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15885.95,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,33808.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32118.5,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,30549.89,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,33808.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43951.64,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,33808.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,43951.64,
VENTRICULAR SHUNT PROCEDURES WITH CC,32,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,18211.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18211.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18211.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23674.66,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9783.31,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18939.73,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10174.65,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,18211.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17300.72,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,19566.61,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,18211.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23674.66,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18211.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,23674.66,
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,33,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13992.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13992.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13992.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18190.15,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8049.68,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14552.12,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8371.67,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,13992.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13292.8,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16099.36,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13992.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18190.15,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13992.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18190.15,
CAROTID ARTERY STENT PROCEDURES WITH MCC,34,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,32098.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32098.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32098.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41728.49,130,MS-DRG,,Case rate,130% Medicare MS-DRG,26548.37,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33382.79,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,27610.33,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,32098.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30493.9,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,53096.75,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,32098.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41728.49,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,32098.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,53096.75,
CAROTID ARTERY STENT PROCEDURES WITH CC,35,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,19369.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19369.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19369.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25179.84,130,MS-DRG,,Case rate,130% Medicare MS-DRG,12257.15,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20143.87,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12747.44,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,19369.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18400.65,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,24514.3,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,19369.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25179.84,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,19369.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,25179.84,
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,36,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15464.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15464.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15464.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20104.41,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7929.14,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16083.53,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8246.31,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,15464.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14691.68,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,15858.27,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15464.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20104.41,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15464.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20104.41,
EXTRACRANIAL PROCEDURES WITH MCC,37,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,27920.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27920.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27920.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36296.64,130,MS-DRG,,Case rate,130% Medicare MS-DRG,16292.59,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29037.31,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16944.3,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,27920.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26524.47,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,32585.18,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,27920.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36296.64,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,27920.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,36296.64,
EXTRACRANIAL PROCEDURES WITH CC,38,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13809.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13809.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13809.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17952.55,130,MS-DRG,,Case rate,130% Medicare MS-DRG,11075.96,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14362.04,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11519,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,13809.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13119.17,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,22151.91,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13809.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17952.55,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13809.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,22151.91,
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,39,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10162.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10162.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10162.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13211.81,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6930.88,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10569.45,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7208.12,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,10162.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9654.78,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13861.75,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10162.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13211.81,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10162.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13861.75,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",40,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,31694.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31694.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31694.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41202.66,130,MS-DRG,,Case rate,130% Medicare MS-DRG,17957.16,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32962.12,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18675.46,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,31694.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30109.63,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,35914.32,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,31694.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41202.66,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,31694.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,41202.66,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",41,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,18822.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18822.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18822.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24469.09,130,MS-DRG,,Case rate,130% Medicare MS-DRG,17496.8,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19575.28,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18196.68,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,18822.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17881.26,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,34993.6,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,18822.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24469.09,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18822.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,34993.6,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",42,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14921.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14921.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14921.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19397.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8757.79,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15518.24,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9108.11,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,14921.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14175.31,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,17515.58,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14921.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19397.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14921.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,19397.79,
SPINAL DISORDERS AND INJURIES WITH CC/MCC,52,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,16548.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16548.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16548.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21512.47,130,MS-DRG,,Case rate,130% Medicare MS-DRG,47476.69,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17209.97,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,49375.79,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,16548.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15720.65,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,94953.38,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,16548.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21512.47,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16548.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,94953.38,
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,53,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8913.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8913.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8913.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11587.84,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4925.88,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9270.27,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5122.92,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8913.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8468.03,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9851.76,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8913.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11587.84,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8913.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11587.84,
NERVOUS SYSTEM NEOPLASMS WITH MCC,54,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12805.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12805.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12805.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16646.75,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10326.66,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13317.4,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10739.73,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,12805.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12164.93,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,20653.31,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12805.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16646.75,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12805.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20653.31,
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,55,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9624.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9624.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9624.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12511.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8230.19,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10009.12,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8559.4,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9624.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9142.94,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16460.38,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9624.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12511.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9624.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16460.38,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,56,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,20120.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20120.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20120.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26156.09,130,MS-DRG,,Case rate,130% Medicare MS-DRG,17694.88,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20924.87,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18402.68,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,20120.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19114.07,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,35389.75,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,20120.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26156.09,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20120.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,35389.75,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,57,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11928.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11928.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11928.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15507.26,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9676.09,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12405.81,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10063.14,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,11928.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11332.23,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,19352.18,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11928.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15507.26,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11928.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,19352.18,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,58,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14826.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14826.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14826.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19274.85,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7937.01,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15419.88,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8254.5,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,14826.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14085.47,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,15874.02,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14826.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19274.85,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14826.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,19274.85,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,59,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10530.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10530.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10530.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13689.08,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7919.44,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10951.26,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8236.23,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,10530.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10003.56,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,15838.89,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10530.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13689.08,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10530.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15838.89,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,60,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8227.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8227.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8227.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10695.28,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5145.76,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8556.23,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5351.6,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8227.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7815.78,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10291.52,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8227.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10695.28,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8227.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10695.28,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",61,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,23368.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23368.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23368.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30379.25,130,MS-DRG,,Case rate,130% Medicare MS-DRG,14022.88,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24303.4,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14583.81,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,23368.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22200.22,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,28045.76,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,23368.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30379.25,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,23368.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,30379.25,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",62,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15969.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15969.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15969.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20760.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10241.25,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16608.32,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10650.9,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,15969.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15171.06,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,20482.49,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15969.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20760.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15969.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20760.4,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",63,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12910.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12910.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12910.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16784.13,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9023.1,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13427.3,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9384.03,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,12910.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12265.33,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,18046.21,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12910.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16784.13,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12910.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18046.21,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,64,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,17012.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17012.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17012.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22116.81,130,MS-DRG,,Case rate,130% Medicare MS-DRG,16268.96,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17693.45,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16919.73,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,17012.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16162.28,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,32537.93,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,17012.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22116.81,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17012.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,32537.93,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,65,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9172.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9172.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9172.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11924.63,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8793.53,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9539.7,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9145.27,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9172.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8714.15,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,17587.06,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9172.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11924.63,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9172.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17587.06,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,66,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6559.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6559.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6559.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8526.88,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4968.28,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6821.51,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5167.01,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6559.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6231.18,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9936.56,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6559.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8526.88,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6559.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9936.56,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,67,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12355.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12355.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12355.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16062.02,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6852.13,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12849.62,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7126.22,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,12355.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11737.63,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13704.26,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12355.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16062.02,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12355.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16062.02,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,68,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8017.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8017.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8017.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10422.54,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4796.25,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8338.03,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4988.1,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8017.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7616.47,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9592.5,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8017.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10422.54,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8017.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10422.54,
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,69,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7442.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7442.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7442.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9675.63,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4603.02,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7740.5,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4787.14,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7442.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7070.65,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9206.04,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7442.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9675.63,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7442.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9675.63,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,70,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15316.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15316.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15316.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19911.23,130,MS-DRG,,Case rate,130% Medicare MS-DRG,11473.93,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15928.98,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11932.89,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,15316.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14550.51,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,22947.85,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15316.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19911.23,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15316.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,22947.85,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,71,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9533.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9533.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9533.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12393.63,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7306.44,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9914.9,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7598.7,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9533.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9056.88,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14612.87,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9533.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12393.63,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9533.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,14612.87,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,72,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7318.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7318.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7318.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9513.44,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4122.06,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7610.75,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4286.95,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7318.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6952.13,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8244.12,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7318.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9513.44,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7318.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9513.44,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,73,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13119.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13119.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13119.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17054.8,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9050.97,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13643.84,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9413.01,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,13119.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12463.13,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,18101.93,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13119.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17054.8,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13119.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18101.93,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,74,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9250.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9250.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9250.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12025.85,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5746.05,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9620.68,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5975.9,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9250.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8788.12,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11492.1,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9250.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12025.85,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9250.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12025.85,
VIRAL MENINGITIS WITH CC/MCC,75,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,16304.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16304.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16304.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21195.32,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5611.58,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16956.25,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5836.04,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,16304.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15488.89,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11223.15,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,16304.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21195.32,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16304.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,21195.32,
VIRAL MENINGITIS WITHOUT CC/MCC,76,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8426.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8426.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8426.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10954.57,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3348.53,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8763.65,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3482.47,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8426.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8005.26,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,6697.06,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8426.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10954.57,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8426.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10954.57,
HYPERTENSIVE ENCEPHALOPATHY WITH MCC,77,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13102.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13102.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13102.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17033.11,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6597.11,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13626.49,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6861,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,13102.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12447.27,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13194.23,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13102.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17033.11,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13102.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17033.11,
HYPERTENSIVE ENCEPHALOPATHY WITH CC,78,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9176.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9176.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9176.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11929.78,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6020.45,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9543.82,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6261.27,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9176.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8717.91,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12040.9,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9176.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11929.78,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9176.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12040.9,
HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,79,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6982.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6982.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6982.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9077.5,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4034.23,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7262,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4195.6,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6982.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6633.56,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8068.46,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6982.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9077.5,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6982.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9077.5,
NONTRAUMATIC STUPOR AND COMA WITH MCC,80,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,18647.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18647.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18647.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24241.83,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4767.78,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19393.46,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4958.49,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,18647.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17715.18,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9535.56,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,18647.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24241.83,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18647.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,24241.83,
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,81,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8323.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8323.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8323.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10820.28,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3184.38,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8656.22,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3311.75,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8323.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7907.13,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,6368.75,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8323.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10820.28,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8323.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10820.28,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,82,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,19200.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19200.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19200.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24960.85,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10841.53,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19968.68,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11275.2,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,19200.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18240.62,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,21683.07,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,19200.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24960.85,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,19200.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,24960.85,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,83,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11874.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11874.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11874.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15437.03,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7216.18,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12349.63,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7504.83,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,11874.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11280.91,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14432.36,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11874.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15437.03,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11874.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15437.03,
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,84,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8404.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8404.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8404.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10925.64,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5323.24,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8740.51,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5536.18,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8404.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7984.12,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10646.49,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8404.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10925.64,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8404.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10925.64,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,85,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,19156.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19156.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19156.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24904.02,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9403.51,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19923.22,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9779.65,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,19156.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18199.09,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,18807.02,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,19156.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24904.02,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,19156.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,24904.02,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,86,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11562.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11562.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11562.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15031.04,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5246.92,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12024.83,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5456.8,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,11562.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10984.22,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10493.84,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11562.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15031.04,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11562.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15031.04,
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,87,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8138.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8138.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8138.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10579.56,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4057.85,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8463.64,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4220.17,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8138.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7731.21,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8115.7,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8138.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10579.56,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8138.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10579.56,
CONCUSSION WITH MCC,88,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13284.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13284.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13284.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17269.68,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8123.58,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13815.74,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8448.53,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,13284.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12620.15,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16247.16,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13284.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17269.68,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13284.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17269.68,
CONCUSSION WITH CC,89,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10233.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10233.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10233.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13303.75,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6509.28,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10643,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6769.66,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,10233.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9721.97,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13018.56,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10233.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13303.75,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10233.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13303.75,
CONCUSSION WITHOUT CC/MCC,90,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8524.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8524.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8524.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11081.63,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3878.55,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8865.3,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4033.7,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8524.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8098.11,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7757.11,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8524.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11081.63,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8524.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11081.63,
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,91,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15313.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15313.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15313.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19908.12,130,MS-DRG,,Case rate,130% Medicare MS-DRG,13962.31,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15926.5,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14520.81,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,15313.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14548.24,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,27924.61,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15313.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19908.12,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15313.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,27924.61,
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,92,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9249.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9249.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9249.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12024.82,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6949.05,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9619.85,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7227.02,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9249.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8787.37,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13898.1,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9249.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12024.82,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9249.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13898.1,
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,93,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7249.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7249.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7249.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9424.6,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5083.98,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7539.68,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5287.34,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7249.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6887.21,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10167.95,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7249.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9424.6,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7249.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10167.95,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,94,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,29884.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29884.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29884.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38849.33,130,MS-DRG,,Case rate,130% Medicare MS-DRG,27876.15,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31079.46,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,28991.22,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,29884.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28389.9,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,55752.31,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,29884.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38849.33,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,29884.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,55752.31,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,95,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,20042.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20042.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20042.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26054.85,130,MS-DRG,,Case rate,130% Medicare MS-DRG,22308.19,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20843.88,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,23200.54,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,20042.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19040.08,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,44616.39,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,20042.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26054.85,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20042.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,44616.39,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,96,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,18417.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18417.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18417.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23942.24,130,MS-DRG,,Case rate,130% Medicare MS-DRG,11865.84,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19153.79,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12340.48,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,18417.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17496.25,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,23731.68,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,18417.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23942.24,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18417.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,23942.24,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,97,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,29996.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29996.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29996.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38996.04,130,MS-DRG,,Case rate,130% Medicare MS-DRG,21202.72,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31196.83,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22050.84,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,29996.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28497.1,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,42405.43,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,29996.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38996.04,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,29996.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,42405.43,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,98,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,18216.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18216.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18216.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23681.91,130,MS-DRG,,Case rate,130% Medicare MS-DRG,12261.39,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18945.52,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12751.85,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,18216.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17306.01,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,24522.78,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,18216.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23681.91,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18216.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,24522.78,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,99,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11586.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11586.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11586.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15063.05,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5967.75,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12050.44,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6206.46,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,11586.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11007.61,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11935.5,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11586.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15063.05,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11586.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15063.05,
SEIZURES WITH MCC,100,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,16850.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16850.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16850.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21905.05,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10286.68,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17524.04,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10698.15,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,16850.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16007.54,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,20573.35,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,16850.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21905.05,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16850.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,21905.05,
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8324.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8324.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8324.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10821.29,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4638.15,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8657.03,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4823.68,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8324.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7907.87,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9276.3,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8324.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10821.29,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8324.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10821.29,
HEADACHES WITH MCC,102,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10684.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10684.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10684.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13889.51,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5544.94,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11111.61,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5766.75,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,10684.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10150.03,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11089.89,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10684.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13889.51,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10684.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13889.51,
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7790.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7790.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7790.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10127.08,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4271.07,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8101.66,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4441.92,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7790.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7400.56,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8542.15,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7790.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10127.08,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7790.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10127.08,
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,21020.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21020.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21020.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27326.56,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10977.22,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21861.25,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11416.32,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,21020.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19969.41,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,21954.44,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,21020.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27326.56,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21020.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,27326.56,
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10884.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10884.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10884.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14149.84,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7064.75,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11319.87,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7347.34,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,10884.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10340.27,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14129.49,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10884.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14149.84,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10884.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,14149.84,
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13527.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13527.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13527.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17585.8,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7617.79,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14068.64,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7922.5,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,13527.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12851.16,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,15235.57,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13527.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17585.8,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13527.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17585.8,
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15644.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15644.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15644.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20337.86,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7781.34,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16270.29,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8092.59,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,15644.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14862.28,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,15562.67,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15644.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20337.86,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15644.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20337.86,
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10619.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10619.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10619.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13804.78,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5701.83,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11043.82,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5929.91,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,10619.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10088.11,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11403.66,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10619.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13804.78,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10619.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13804.78,
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11277.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11277.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11277.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14660.17,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3795.57,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11728.13,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3947.39,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,11277.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10713.2,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7591.13,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11277.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14660.17,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11277.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,14660.17,
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7012.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7012.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7012.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9115.72,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3235.86,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7292.57,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3365.3,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7012.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6661.49,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,6471.73,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7012.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9115.72,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7012.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9115.72,
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7484.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7484.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7484.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9730.38,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5023.4,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7784.31,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5224.34,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7484.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7110.66,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10046.8,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7484.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9730.38,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7484.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10046.8,
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11600.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11600.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11600.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15080.62,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5243.89,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12064.5,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5453.65,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,11600.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11020.46,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10487.78,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11600.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15080.62,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11600.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15080.62,
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7433.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7433.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7433.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9663.24,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3269.78,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7730.59,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3400.58,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7433.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7061.6,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,6539.57,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7433.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9663.24,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7433.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9663.24,
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,22171.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22171.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22171.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28822.43,130,MS-DRG,,Case rate,130% Medicare MS-DRG,12311.06,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23057.94,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12803.51,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,22171.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21062.55,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,24622.12,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,22171.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28822.43,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22171.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,28822.43,
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9394.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9394.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9394.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12212.84,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6273.65,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9770.27,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6524.6,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,9394.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8924.77,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12547.3,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9394.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12212.84,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9394.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12547.3,
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13053.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13053.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13053.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16969.06,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5606.12,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13575.24,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5830.37,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,13053.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12400.46,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11212.25,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13053.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16969.06,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13053.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16969.06,
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7975.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7975.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7975.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10367.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4144.47,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8294.23,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4310.25,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,7975.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7576.46,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8288.95,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7975.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10367.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7975.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10367.79,
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10534.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10534.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10534.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13694.25,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6233.67,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10955.4,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6483.02,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,10534.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10007.34,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12467.34,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10534.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13694.25,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10534.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13694.25,
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,31119.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31119.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31119.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40454.71,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4006.97,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32363.77,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4167.25,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,31119.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29563.06,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8013.94,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,31119.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40454.71,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,31119.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,40454.71,
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,17558.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17558.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17558.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22826.53,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3364.89,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18261.22,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3499.48,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,17558.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16680.93,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,6729.77,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,17558.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22826.53,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17558.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,22826.53,
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13373.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13373.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13373.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17385.38,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8050.28,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13908.3,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8372.3,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,13373.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12704.7,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16100.57,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13373.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17385.38,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13373.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17385.38,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,27523.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27523.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27523.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35780.11,130,MS-DRG,,Case rate,130% Medicare MS-DRG,13692.15,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28624.09,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14239.84,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,27523.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26147,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,27384.29,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,27523.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35780.11,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,27523.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,35780.11,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14847.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14847.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14847.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19301.72,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3848.27,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15441.38,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4002.2,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,14847.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14105.11,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7696.53,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14847.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19301.72,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14847.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,19301.72,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10799.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10799.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10799.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14039.3,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4248.66,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11231.44,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4418.61,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,10799.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10259.49,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8497.32,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10799.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14039.3,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10799.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,14039.3,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,17871.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17871.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17871.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23232.52,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8164.16,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18586.02,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8490.74,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,17871.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16977.61,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16328.33,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,17871.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23232.52,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17871.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,23232.52,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10916.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10916.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10916.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14191.15,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6099.8,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11352.92,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6343.8,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,10916.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10370.46,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12199.6,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10916.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14191.15,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10916.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,14191.15,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8165.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8165.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8165.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10615.72,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4615.74,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8492.58,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4800.37,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8165.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7757.64,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9231.48,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8165.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10615.72,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8165.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10615.72,
DYSEQUILIBRIUM,149,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7013.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7013.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7013.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9117.78,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4069.36,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7294.23,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4232.14,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7013.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6663,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8138.72,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7013.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9117.78,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7013.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9117.78,
EPISTAXIS WITH MCC,150,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11541.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11541.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11541.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15004.17,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5049.45,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12003.34,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5251.43,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,11541.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10964.59,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10098.9,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11541.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15004.17,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11541.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15004.17,
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7220.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7220.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7220.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9386.38,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3091.09,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7509.1,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3214.74,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7220.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6859.28,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,6182.18,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7220.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9386.38,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7220.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9386.38,
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10538.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10538.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10538.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13699.41,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4575.15,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10959.53,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4758.16,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,10538.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10011.11,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9150.31,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10538.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13699.41,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10538.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13699.41,
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6935,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6935,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6935,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9015.5,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3900.97,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7212.4,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4057.01,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6935,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6588.25,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7801.93,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6935,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9015.5,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6935,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9015.5,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13319.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13319.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13319.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17315.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6521.4,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13852.11,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6782.26,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,13319.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12653.37,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13042.79,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13319.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17315.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13319.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17315.14,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8618.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8618.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8618.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11203.53,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4125.09,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8962.82,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4290.1,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8618.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8187.2,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8250.18,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8618.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11203.53,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8618.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11203.53,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6304.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6304.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6304.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8196.29,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3271,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6557.03,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3401.84,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6304.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5989.6,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,6541.99,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6304.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8196.29,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6304.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,8196.29,
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14660.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14660.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14660.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19058.94,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6329.98,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15247.15,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6583.19,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,14660.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13927.68,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12659.97,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14660.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19058.94,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14660.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,19058.94,
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8553.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8553.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8553.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11119.86,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5603.1,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8895.89,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5827.22,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8553.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8126.05,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11206.19,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8553.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11119.86,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8553.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11206.19,
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6461.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6461.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6461.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8399.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4375.26,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6719.84,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4550.27,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6461.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6138.31,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8750.52,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6461.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8399.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6461.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,8750.52,
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,38553.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38553.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38553.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,50119.03,130,MS-DRG,,Case rate,130% Medicare MS-DRG,34478.12,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40095.22,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,35857.26,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,38553.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36625.45,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,68956.23,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,38553.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,50119.03,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,38553.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,68956.23,
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,21362.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21362.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21362.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27771.8,130,MS-DRG,,Case rate,130% Medicare MS-DRG,15990.93,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22217.44,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16630.58,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,21362.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20294.77,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,31981.86,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,21362.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27771.8,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21362.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,31981.86,
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,16006.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16006.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16006.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20808.96,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10907.56,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16647.17,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11343.87,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,16006.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15206.55,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,21815.12,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,16006.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20808.96,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16006.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,21815.12,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,33341.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33341.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33341.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43344.2,130,MS-DRG,,Case rate,130% Medicare MS-DRG,25313.87,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34675.36,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,26326.45,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,33341.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31674.61,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,50627.75,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,33341.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43344.2,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,33341.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,50627.75,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15557.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15557.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15557.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20224.24,130,MS-DRG,,Case rate,130% Medicare MS-DRG,11685.33,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16179.39,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12152.75,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,15557.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14779.25,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,23370.66,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15557.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20224.24,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15557.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,23370.66,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11869.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11869.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11869.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15429.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8083.6,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12343.83,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8406.95,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,11869.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11275.62,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16167.2,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11869.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15429.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11869.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16167.2,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,25531.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25531.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25531.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33191.26,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7124.11,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26553.01,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7409.08,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25531.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24255.15,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14248.22,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,25531.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33191.26,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,25531.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,33191.26,
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12244.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12244.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12244.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15918.44,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9594.92,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12734.75,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9978.72,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,12244.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11632.7,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,19189.84,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12244.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15918.44,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12244.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,19189.84,
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7577.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7577.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7577.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9850.22,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5864.17,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7880.17,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6098.74,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7577.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7198.24,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11728.34,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7577.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9850.22,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7577.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11728.34,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14576.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14576.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14576.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18949.44,130,MS-DRG,,Case rate,130% Medicare MS-DRG,11595.68,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15159.55,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12059.52,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,14576.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13847.67,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,23191.36,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14576.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18949.44,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14576.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,23191.36,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8936.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8936.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8936.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11617.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8931.03,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9294.23,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9288.28,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8936.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8489.92,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,17862.06,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8936.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11617.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8936.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17862.06,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7161.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7161.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7161.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9309.94,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4405.55,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7447.95,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4581.77,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7161.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6803.42,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8811.09,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7161.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9309.94,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7161.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9309.94,
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14908.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14908.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14908.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19381.26,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10797.32,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15505.01,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11229.22,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,14908.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14163.23,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,21594.63,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14908.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19381.26,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14908.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,21594.63,
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9845.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9845.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9845.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12799.62,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8044.83,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10239.69,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8366.63,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9845.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9353.57,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16089.67,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9845.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12799.62,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9845.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16089.67,
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7443.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7443.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7443.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9676.68,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4589.09,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7741.34,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4772.65,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7443.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7071.42,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9178.17,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7443.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9676.68,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7443.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9676.68,
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13607.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13607.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13607.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17690.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7952.15,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14152.11,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8270.25,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,13607.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12927.41,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,15904.31,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13607.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17690.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13607.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17690.14,
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9454.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9454.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9454.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12291.36,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5052.48,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9833.09,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5254.58,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9454.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8982.15,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10104.95,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9454.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12291.36,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9454.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12291.36,
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7101.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7101.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7101.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9231.42,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3123.8,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7385.13,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3248.76,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7101.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6746.04,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,6247.6,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7101.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9231.42,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7101.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9231.42,
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13429.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13429.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13429.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17458.73,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9867.5,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13966.98,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10262.21,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,13429.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12758.3,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,19735.01,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13429.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17458.73,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13429.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,19735.01,
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9013.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9013.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9013.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11716.97,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7030.22,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9373.57,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7311.43,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9013.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8562.4,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14060.44,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9013.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11716.97,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9013.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,14060.44,
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7027.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7027.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7027.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9136.39,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3922.77,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7309.11,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4079.69,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7027.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6676.59,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7845.54,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7027.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9136.39,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7027.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9136.39,
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10886.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10886.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10886.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14151.9,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8497.93,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11321.52,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8837.85,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,10886.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10341.78,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16995.85,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10886.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14151.9,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10886.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16995.85,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9853.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9853.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9853.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12808.91,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6784.89,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10247.13,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7056.29,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9853.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9360.36,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13569.79,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9853.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12808.91,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9853.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13569.79,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7842.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7842.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7842.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10195.26,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5431.67,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8156.21,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5648.94,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7842.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7450.38,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10863.34,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7842.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10195.26,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7842.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10863.34,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6195.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6195.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6195.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8054.75,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4260.78,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6443.8,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4431.21,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6195.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5886.16,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8521.55,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6195.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8054.75,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6195.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,8521.55,
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11637.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11637.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11637.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15129.17,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8139.93,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12103.33,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8465.54,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,11637.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11055.93,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16279.87,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11637.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15129.17,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11637.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16279.87,
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7629.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7629.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7629.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9918.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5633.99,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7934.72,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5859.35,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7629.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7248.06,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11267.98,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7629.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9918.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7629.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11267.98,
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6067.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6067.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6067.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7887.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4247.45,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6309.92,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4417.35,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6067.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5763.87,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8494.9,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6067.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7887.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6067.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,8494.9,
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,16157.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16157.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16157.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21005.23,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7873.41,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16804.18,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8188.35,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,16157.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15349.98,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,15746.82,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,16157.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21005.23,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16157.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,21005.23,
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9022.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9022.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9022.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11729.37,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6191.27,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9383.49,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6438.92,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9022.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8571.46,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12382.54,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9022.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11729.37,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9022.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12382.54,
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7279.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7279.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7279.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9463.87,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4108.73,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7571.1,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4273.09,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7279.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6915.91,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8217.47,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7279.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9463.87,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7279.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9463.87,
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15193.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15193.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15193.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19752.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9172.12,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15801.71,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9539.01,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,15193.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14434.25,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,18344.23,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15193.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19752.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15193.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,19752.14,
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9654.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9654.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9654.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12550.64,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4617.56,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10040.51,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4802.26,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9654.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9171.62,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9235.11,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9654.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12550.64,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9654.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12550.64,
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6706.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6706.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6706.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8719.01,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3734.39,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6975.21,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3883.77,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6706.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6371.58,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7468.77,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6706.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8719.01,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6706.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,8719.01,
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8704.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8704.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8704.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11316.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5239.65,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9052.91,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5449.24,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8704.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8269.48,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10479.3,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8704.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11316.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8704.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11316.14,
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6617.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6617.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6617.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8603.31,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3756.19,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6882.65,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3906.44,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6617.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6287.03,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7512.39,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6617.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8603.31,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6617.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,8603.31,
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7635.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7635.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7635.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9925.64,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4828.35,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7940.51,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5021.49,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7635.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7253.35,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9656.71,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7635.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9925.64,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7635.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9925.64,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15481.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15481.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15481.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20126.09,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7094.43,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16100.87,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7378.21,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,15481.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14707.53,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14188.85,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15481.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20126.09,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15481.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20126.09,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8355.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8355.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8355.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10861.58,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4163.25,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8689.26,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4329.78,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8355.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7937.31,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8326.5,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8355.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10861.58,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8355.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10861.58,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,55991.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,55991.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,55991.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,72788.56,130,MS-DRG,,Case rate,130% Medicare MS-DRG,42319.42,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58230.85,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,44012.22,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,55991.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,53191.64,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,84638.84,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,55991.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,72788.56,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,55991.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,84638.84,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,22581.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22581.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22581.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29356.54,130,MS-DRG,,Case rate,130% Medicare MS-DRG,12879.85,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23485.23,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13395.05,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,22581.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21452.85,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,25759.7,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,22581.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29356.54,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22581.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,29356.54,
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,86686.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,86686.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,86686.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,112692.7,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3312.19,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90154.16,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3444.68,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86686.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82352.36,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,6624.37,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,86686.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,112692.7,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,86686.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,112692.7,
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,82269.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82269.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82269.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,106949.9,130,MS-DRG,,Case rate,130% Medicare MS-DRG,77735.22,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85559.92,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,80844.68,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,82269.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,78155.69,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,155470.44,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,82269.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,106949.9,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,82269.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,155470.44,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,78220.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,78220.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,78220.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,101686.46,130,MS-DRG,,Case rate,130% Medicare MS-DRG,65044.36,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81349.16,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,67646.18,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,78220.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,74309.33,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,130088.72,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,78220.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,101686.46,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,78220.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,130088.72,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,51678.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,51678.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,51678.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,67182.13,130,MS-DRG,,Case rate,130% Medicare MS-DRG,38091.35,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53745.7,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,39615.03,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,51678.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49094.63,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,76182.71,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,51678.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,67182.13,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,51678.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,76182.71,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,46365.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46365.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46365.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,60275.07,130,MS-DRG,,Case rate,130% Medicare MS-DRG,30386.34,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48220.06,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,31601.82,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,46365.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,44047.17,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,60772.68,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,46365.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,60275.07,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,46365.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,60772.68,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,62373.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,62373.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,62373.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,81086.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,42096.51,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64868.91,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,43780.4,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,62373.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,59255.25,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,84193.01,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,62373.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,81086.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,62373.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,84193.01,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,42772.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42772.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42772.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,55604.59,130,MS-DRG,,Case rate,130% Medicare MS-DRG,33648.25,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44483.67,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,34994.2,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,42772.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40634.12,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,67296.5,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,42772.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,55604.59,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,42772.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,67296.5,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,38036.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38036.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38036.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49447.53,130,MS-DRG,,Case rate,130% Medicare MS-DRG,32997.69,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39558.02,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,34317.62,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,38036.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36134.73,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,65995.37,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,38036.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49447.53,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,38036.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,65995.37,
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,41136.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41136.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41136.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,53477.52,130,MS-DRG,,Case rate,130% Medicare MS-DRG,34572,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42782.01,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,35954.91,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,41136.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39079.72,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,69144.01,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,41136.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,53477.52,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,41136.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,69144.01,
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,26362.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26362.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26362.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34271.84,130,MS-DRG,,Case rate,130% Medicare MS-DRG,22120.41,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27417.47,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,23005.24,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,26362.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25044.8,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,44240.83,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,26362.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34271.84,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,26362.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,44240.83,
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,65584.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,65584.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,65584.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,85259.71,130,MS-DRG,,Case rate,130% Medicare MS-DRG,39866.17,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68207.77,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,41460.85,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,65584.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,62305.17,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,79732.34,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,65584.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,85259.71,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,65584.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,85259.71,
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,48367.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,48367.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,48367.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,62877.36,130,MS-DRG,,Case rate,130% Medicare MS-DRG,33711.85,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50301.89,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,35060.35,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,48367.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,45948.84,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,67423.71,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,48367.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,62877.36,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,48367.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,67423.71,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,63076.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,63076.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,63076.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,81999.37,130,MS-DRG,,Case rate,130% Medicare MS-DRG,39436.7,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65599.5,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,41014.2,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,63076.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,59922.62,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,78873.41,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,63076.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,81999.37,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,63076.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,81999.37,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,42401.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42401.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42401.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,55122.15,130,MS-DRG,,Case rate,130% Medicare MS-DRG,27404.89,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44097.72,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,28501.1,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,42401.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40281.57,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,54809.78,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,42401.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,55122.15,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,42401.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,55122.15,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,47826.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47826.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47826.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,62174.88,130,MS-DRG,,Case rate,130% Medicare MS-DRG,32527.63,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49739.9,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,33828.76,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,47826.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,45435.49,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,65055.26,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,47826.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,62174.88,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,47826.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,65055.26,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,33209.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33209.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33209.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43172.7,130,MS-DRG,,Case rate,130% Medicare MS-DRG,23560.26,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34538.16,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,24502.68,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,33209.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31549.28,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,47120.51,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,33209.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43172.7,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,33209.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,47120.51,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,39293.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39293.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39293.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,51081.84,130,MS-DRG,,Case rate,130% Medicare MS-DRG,33558.6,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40865.47,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,34900.97,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,39293.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37329.03,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,67117.2,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,39293.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,51081.84,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,39293.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,67117.2,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,23419.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23419.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23419.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30445.38,130,MS-DRG,,Case rate,130% Medicare MS-DRG,16278.05,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24356.3,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16929.18,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,23419.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22248.54,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,32556.1,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,23419.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30445.38,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,23419.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,32556.1,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12173.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12173.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12173.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15825.46,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6852.74,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12660.37,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7126.85,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,12173.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11564.76,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13705.47,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12173.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15825.46,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12173.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15825.46,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,28552.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28552.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28552.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37117.93,130,MS-DRG,,Case rate,130% Medicare MS-DRG,25767.57,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29694.34,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,26798.29,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,28552.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27124.64,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,51535.15,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,28552.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37117.93,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,28552.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,51535.15,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,19195.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19195.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19195.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24953.6,130,MS-DRG,,Case rate,130% Medicare MS-DRG,16539.73,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19962.88,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17201.33,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,19195.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18235.33,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,33079.46,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,19195.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24953.6,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,19195.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,33079.46,
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15634.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15634.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15634.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20324.45,130,MS-DRG,,Case rate,130% Medicare MS-DRG,12817.46,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16259.56,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13330.17,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,15634.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14852.48,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,25634.92,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15634.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20324.45,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15634.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,25634.92,
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,37105.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37105.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37105.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,48236.77,130,MS-DRG,,Case rate,130% Medicare MS-DRG,30007.15,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38589.42,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,31207.45,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,37105.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35249.95,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,60014.3,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,37105.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,48236.77,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,37105.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,60014.3,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,19776.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19776.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19776.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25709.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,14770.36,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20567.83,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15361.19,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,19776.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18787.92,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,29540.73,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,19776.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25709.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,19776.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,29540.73,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13706.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13706.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13706.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17818.24,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9037.04,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14254.59,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9398.52,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,13706.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13021.02,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,18074.07,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13706.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17818.24,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13706.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18074.07,
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,27747.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27747.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27747.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36071.43,130,MS-DRG,,Case rate,130% Medicare MS-DRG,20592.74,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28857.14,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21416.46,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,27747.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26359.89,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,41185.47,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,27747.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36071.43,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,27747.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,41185.47,
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,21368.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21368.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21368.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27779.04,130,MS-DRG,,Case rate,130% Medicare MS-DRG,17427.14,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22223.23,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18124.24,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,21368.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20300.07,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,34854.28,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,21368.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27779.04,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21368.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,34854.28,
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14884.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14884.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14884.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19349.25,130,MS-DRG,,Case rate,130% Medicare MS-DRG,11457.57,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15479.4,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11915.88,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,14884.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14139.84,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,22915.14,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14884.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19349.25,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14884.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,22915.14,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,22928.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22928.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22928.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29806.93,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9150.91,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23845.55,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9516.96,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,22928.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21781.99,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,18301.83,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,22928.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29806.93,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22928.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,29806.93,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14125.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14125.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14125.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18363.68,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8941.93,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14690.95,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9299.62,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,14125.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13419.61,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,17883.87,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14125.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18363.68,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14125.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18363.68,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8970.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8970.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8970.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11662.22,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4570.31,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9329.78,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4753.12,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,8970.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8522.39,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9140.62,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8970.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11662.22,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8970.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11662.22,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,22620.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22620.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22620.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29406.1,130,MS-DRG,,Case rate,130% Medicare MS-DRG,12902.26,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23524.88,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13418.36,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,22620.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21489.08,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,25804.52,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,22620.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29406.1,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22620.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,29406.1,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15929.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15929.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15929.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20707.71,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9027.95,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16566.17,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9389.07,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,15929.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15132.56,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,18055.9,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15929.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20707.71,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15929.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20707.71,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,27440.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27440.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27440.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35672.66,130,MS-DRG,,Case rate,130% Medicare MS-DRG,17260.56,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28538.13,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17951,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,27440.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26068.48,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,34521.12,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,27440.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35672.66,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,27440.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,35672.66,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,16049.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16049.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16049.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20864.74,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8969.8,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16691.79,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9328.6,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,16049.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15247.31,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,17939.6,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,16049.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20864.74,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16049.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20864.74,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14170.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14170.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14170.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18421.55,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8169.62,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14737.24,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8496.41,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,14170.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13461.9,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16339.23,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14170.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18421.55,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14170.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18421.55,
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,23546.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23546.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23546.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30610.66,130,MS-DRG,,Case rate,130% Medicare MS-DRG,15935.2,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24488.53,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16572.62,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,23546.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22369.33,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,31870.4,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,23546.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30610.66,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,23546.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,31870.4,
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,27049.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27049.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27049.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35164.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,16599.09,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28131.52,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17263.07,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,27049.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25697.06,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,33198.19,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,27049.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35164.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,27049.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,35164.4,
AICD LEAD PROCEDURES,265,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,29180.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29180.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29180.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37934.05,130,MS-DRG,,Case rate,130% Medicare MS-DRG,15158.04,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30347.24,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15764.37,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,29180.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27721.04,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,30316.08,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,29180.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37934.05,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,29180.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,37934.05,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,50731.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,50731.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,50731.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,65950.73,130,MS-DRG,,Case rate,130% Medicare MS-DRG,29199.09,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52760.58,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,30367.07,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,50731.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,48194.76,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,58398.18,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,50731.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,65950.73,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,50731.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,65950.73,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,39877,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39877,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39877,100,MS-DRG,,Case rate,100% Medicare MS-DRG,51840.1,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3333.99,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41472.08,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3467.35,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,39877,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37883.15,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,6667.99,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,39877,100,MS-DRG,,Case rate,100% Medicare MS-DRG,51840.1,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,39877,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,51840.1,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,55567.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,55567.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,55567.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,72237.95,130,MS-DRG,,Case rate,130% Medicare MS-DRG,16100.57,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57790.36,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16744.6,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,55567.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52789.27,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,32201.14,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,55567.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,72237.95,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,55567.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,72237.95,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,34142.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34142.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34142.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,44385.52,130,MS-DRG,,Case rate,130% Medicare MS-DRG,2714.93,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35508.42,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2823.53,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,34142.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32435.57,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,5429.85,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,34142.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,44385.52,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,34142.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,44385.52,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,41281.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41281.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41281.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,53665.52,130,MS-DRG,,Case rate,130% Medicare MS-DRG,1731.81,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42932.42,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1801.08,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,41281.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39217.11,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,3463.62,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,41281.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,53665.52,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,41281.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,53665.52,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,28560.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28560.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28560.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37129.29,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3253.43,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29703.43,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3383.57,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,28560.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27132.94,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,6506.86,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,28560.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37129.29,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,28560.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,37129.29,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,20481.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20481.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20481.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26626.13,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21300.91,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,20481.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19457.56,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,20481.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26626.13,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20481.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,26626.13,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,32063.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32063.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32063.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41683.03,130,MS-DRG,,Case rate,130% Medicare MS-DRG,23594.78,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33346.42,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,24538.59,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,32063.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30460.68,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,47189.57,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,32063.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41683.03,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,32063.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,47189.57,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,26849.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26849.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26849.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34904.08,130,MS-DRG,,Case rate,130% Medicare MS-DRG,12538.21,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27923.26,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13039.75,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,26849.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25506.83,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,25076.42,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,26849.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34904.08,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,26849.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,34904.08,
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,57006.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,57006.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,57006.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,74108.83,130,MS-DRG,,Case rate,130% Medicare MS-DRG,30322.74,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59287.06,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,31535.67,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57006.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54156.45,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,60645.48,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,57006.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,74108.83,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,57006.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,74108.83,
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC,276,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,50446.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,50446.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,50446.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,65579.85,130,MS-DRG,,Case rate,130% Medicare MS-DRG,21670.35,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52463.88,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22537.18,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50446.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47923.74,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,43340.7,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,50446.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,65579.85,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,50446.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,65579.85,
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,39099.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39099.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39099.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,50829.78,130,MS-DRG,,Case rate,130% Medicare MS-DRG,32710.57,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40663.82,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,34019.01,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39099.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37144.84,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,65421.13,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,39099.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,50829.78,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,39099.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,65421.13,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,36541,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36541,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36541,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47503.3,130,MS-DRG,,Case rate,130% Medicare MS-DRG,21602.51,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38002.64,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22466.62,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36541,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34713.95,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,43205.01,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,36541,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47503.3,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,36541,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,47503.3,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,26529.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26529.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26529.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34488.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,13611.58,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27591.03,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14156.06,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26529.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25203.35,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,27223.17,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,26529.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34488.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,26529.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,34488.79,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13703.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13703.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13703.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17814.1,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10078.91,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14251.28,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10482.07,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,13703.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13017.99,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,20157.82,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13703.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17814.1,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13703.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20157.82,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8351.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8351.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8351.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10856.43,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5963.51,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8685.14,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6202.05,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8351.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7933.55,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11927.02,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8351.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10856.43,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8351.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11927.02,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6802.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6802.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6802.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8842.98,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5963.51,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7074.38,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6202.05,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6802.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6462.18,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11927.02,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6802.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8842.98,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6802.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11927.02,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,16761.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16761.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16761.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21790.37,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7543.28,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17432.29,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7845.02,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,16761.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15923.73,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,15086.56,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,16761.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21790.37,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16761.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,21790.37,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6973.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6973.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6973.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9066.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3583.56,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7252.91,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3726.9,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6973.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6625.25,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7167.12,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6973.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9066.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6973.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9066.14,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,4979.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4979.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4979.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6473.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3487.25,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5178.51,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3626.74,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,4979.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4730.37,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,6974.49,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,4979.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6473.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4979.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,6974.49,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,18225.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18225.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18225.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23693.28,130,MS-DRG,,Case rate,130% Medicare MS-DRG,15609.92,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18954.62,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16234.33,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,18225.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17314.32,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,31219.84,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,18225.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23693.28,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18225.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,31219.84,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9690.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9690.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9690.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12598.17,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8073.3,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10078.54,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8396.24,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9690.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9206.36,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16146.61,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9690.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12598.17,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9690.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16146.61,
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,21701.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21701.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21701.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28211.89,130,MS-DRG,,Case rate,130% Medicare MS-DRG,12696.31,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22569.51,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13204.17,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,21701.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20616.38,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,25392.62,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,21701.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28211.89,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21701.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,28211.89,
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12838.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12838.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12838.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16690.13,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8126.61,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13352.1,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8451.68,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,12838.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12196.63,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16253.22,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12838.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16690.13,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12838.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16690.13,
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9718.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9718.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9718.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12634.32,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7436.06,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10107.46,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7733.51,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9718.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9232.77,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14872.13,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9718.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12634.32,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9718.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,14872.13,
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11298.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11298.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11298.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14688.05,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8376.78,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11750.44,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8711.86,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,11298.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10733.58,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16753.56,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11298.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14688.05,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11298.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16753.56,
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7902.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7902.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7902.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10272.74,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5404.41,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8218.19,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5620.59,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7902.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7507,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10808.82,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7902.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10272.74,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7902.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10808.82,
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,5557.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5557.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5557.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7225.22,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3751.35,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5780.17,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3901.4,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,5557.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5279.97,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7502.7,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,5557.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7225.22,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5557.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,7502.7,
DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,294,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9787.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9787.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9787.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12723.17,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4738.7,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10178.53,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4928.26,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9787.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9297.7,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9477.41,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9787.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12723.17,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9787.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12723.17,
DEEP VEIN THROMBOPHLEBITIS WITHOUT CC/MCC,295,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7430.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7430.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7430.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9659.12,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4738.7,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7727.29,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4928.26,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7430.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7058.59,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9477.41,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7430.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9659.12,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7430.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9659.12,
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13835.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13835.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13835.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17986.63,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10413.88,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14389.3,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10830.44,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,13835.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13144.08,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,20827.76,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13835.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17986.63,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13835.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20827.76,
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6885.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6885.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6885.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8951.46,130,MS-DRG,,Case rate,130% Medicare MS-DRG,2931.78,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7161.17,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3049.05,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6885.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6541.45,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,5863.56,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6885.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8951.46,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6885.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,8951.46,
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,4589.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4589.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4589.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5966.94,130,MS-DRG,,Case rate,130% Medicare MS-DRG,2931.78,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4773.55,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3049.05,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,4589.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4360.45,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,5863.56,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,4589.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5966.94,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4589.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,5966.94,
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13621.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13621.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13621.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17707.69,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7594.77,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14166.15,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7898.56,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,13621.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12940.24,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,15189.54,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13621.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17707.69,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13621.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17707.69,
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9574.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9574.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9574.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12447.36,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6257.29,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9957.89,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6507.59,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9574.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9096.15,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12514.59,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9574.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12447.36,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9574.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12514.59,
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6736.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6736.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6736.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8757.24,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3595.67,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7005.79,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3739.5,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6736.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6399.52,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7191.35,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6736.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8757.24,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6736.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,8757.24,
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10004.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10004.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10004.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13006.23,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4497.62,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10404.98,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4677.53,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,10004.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9504.55,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8995.24,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10004.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13006.23,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10004.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13006.23,
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6325.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6325.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6325.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8223.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4318.93,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6578.51,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4491.69,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6325.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6009.22,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8637.85,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6325.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8223.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6325.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,8637.85,
HYPERTENSION WITH MCC,304,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10226.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10226.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10226.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13294.45,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5352.32,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10635.56,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5566.41,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,10226.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9715.18,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10704.64,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10226.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13294.45,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10226.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13294.45,
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7083.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7083.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7083.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9208.69,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4380.11,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7366.95,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4555.31,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7083.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6729.43,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8760.21,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7083.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9208.69,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7083.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9208.69,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13308.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13308.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13308.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17300.67,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5439.55,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13840.54,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5657.13,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,13308.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12642.8,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10879.09,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13308.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17300.67,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13308.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17300.67,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8586.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8586.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8586.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11162.2,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4225.04,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8929.76,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4394.04,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8586.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8156.99,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8450.07,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8586.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11162.2,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8586.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11162.2,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10649.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10649.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10649.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13844.05,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8159.32,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11075.24,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8485.7,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,10649.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10116.81,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16318.64,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10649.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13844.05,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10649.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16318.64,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7013.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7013.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7013.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9117.78,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5221.48,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7294.23,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5430.34,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7013.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6663,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10442.96,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7013.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9117.78,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7013.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10442.96,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,5490.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5490.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5490.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7137.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3532.07,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5709.92,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3673.36,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,5490.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5215.79,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7064.14,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,5490.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7137.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5490.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,7137.4,
ANGINA PECTORIS,311,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6643.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6643.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6643.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8636.37,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4427.35,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6909.09,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4604.45,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6643.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6311.19,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8854.71,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6643.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8636.37,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6643.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,8854.71,
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7957.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7957.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7957.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10345.06,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4623.01,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8276.05,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4807.93,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7957.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7559.85,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9246.02,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7957.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10345.06,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7957.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10345.06,
CHEST PAIN,313,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6846,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6846,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6846,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8899.8,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4529.12,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7119.84,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4710.29,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6846,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6503.7,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9058.24,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6846,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8899.8,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6846,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9058.24,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,17732.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17732.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17732.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23051.73,130,MS-DRG,,Case rate,130% Medicare MS-DRG,14125.86,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18441.38,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14690.9,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,17732.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16845.5,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,28251.71,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,17732.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23051.73,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17732.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,28251.71,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8782.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8782.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8782.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11417.38,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6946.63,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9133.9,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7224.5,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8782.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8343.47,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13893.25,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8782.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11417.38,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8782.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13893.25,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6600.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6600.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6600.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8580.59,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5322.03,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6864.47,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5534.92,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6600.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6270.43,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10644.06,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6600.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8580.59,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6600.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10644.06,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,35758.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35758.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35758.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46485.74,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37188.59,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,35758.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33970.35,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,35758.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46485.74,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,35758.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,46485.74,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,18785.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18785.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18785.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24420.55,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19536.44,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,18785.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17845.79,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,18785.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24420.55,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18785.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,24420.55,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,23940.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23940.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23940.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31122.01,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24897.61,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23940.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22743.01,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,23940.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31122.01,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,23940.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,31122.01,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15585.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15585.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15585.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20261.44,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16209.15,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15585.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14806.43,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,15585.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20261.44,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15585.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20261.44,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,33994.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33994.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33994.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,44193.37,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35354.7,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33994.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32295.16,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,33994.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,44193.37,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,33994.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,44193.37,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,24686.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24686.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24686.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32092.07,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25673.66,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24686.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23451.9,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,24686.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32092.07,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,24686.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,32092.07,
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,22109.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22109.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22109.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28741.84,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22993.47,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22109.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21003.65,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,22109.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28741.84,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22109.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,28741.84,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,41456.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41456.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41456.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,53893.84,130,MS-DRG,,Case rate,130% Medicare MS-DRG,28323.8,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43115.07,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,29456.77,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,41456.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39383.96,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,56647.59,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,41456.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,53893.84,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,41456.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,56647.59,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,20941.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20941.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20941.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27224.29,130,MS-DRG,,Case rate,130% Medicare MS-DRG,14168.26,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21779.43,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14735,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,20941.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19894.67,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,28336.52,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,20941.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27224.29,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20941.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,28336.52,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13788.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13788.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13788.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17925.69,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8614.83,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14340.55,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8959.43,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,13788.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13099.54,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,17229.67,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13788.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17925.69,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13788.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17925.69,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,36989.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36989.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36989.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,48085.96,130,MS-DRG,,Case rate,130% Medicare MS-DRG,29534.67,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38468.77,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,30716.08,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,36989.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35139.74,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,59069.34,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,36989.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,48085.96,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,36989.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,59069.34,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,19946.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19946.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19946.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25929.85,130,MS-DRG,,Case rate,130% Medicare MS-DRG,15304.63,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20743.88,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15916.82,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,19946.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18948.74,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,30609.25,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,19946.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25929.85,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,19946.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,30609.25,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14382.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14382.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14382.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18697.38,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10212.17,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14957.9,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10620.66,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,14382.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13663.47,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,20424.34,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14382.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18697.38,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14382.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20424.34,
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,30135.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30135.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30135.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39175.77,130,MS-DRG,,Case rate,130% Medicare MS-DRG,21672.77,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31340.62,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22539.7,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,30135.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28628.45,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,43345.54,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,30135.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39175.77,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,30135.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,43345.54,
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,17620.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17620.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17620.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22907.11,130,MS-DRG,,Case rate,130% Medicare MS-DRG,11927.02,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18325.68,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12404.11,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,17620.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16739.81,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,23854.04,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,17620.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22907.11,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17620.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,23854.04,
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13850.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13850.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13850.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18006.25,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9237.54,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14405,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9607.04,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,13850.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13158.41,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,18475.07,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13850.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18006.25,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13850.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18475.07,
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,29505.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29505.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29505.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38356.57,130,MS-DRG,,Case rate,130% Medicare MS-DRG,29366.88,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30685.25,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,30541.58,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,29505.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28029.8,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,58733.76,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,29505.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38356.57,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,29505.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,58733.76,
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,17825.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17825.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17825.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23173.63,130,MS-DRG,,Case rate,130% Medicare MS-DRG,14923.62,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18538.9,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15520.57,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,17825.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16934.58,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,29847.23,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,17825.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23173.63,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17825.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,29847.23,
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12987.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12987.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12987.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16883.31,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9124.26,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13506.65,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9489.24,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,12987.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12337.8,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,18248.52,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12987.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16883.31,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12987.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18248.52,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,22872.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22872.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22872.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29734.63,130,MS-DRG,,Case rate,130% Medicare MS-DRG,15623.25,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23787.7,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16248.19,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,22872.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21729.15,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,31246.49,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,22872.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29734.63,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22872.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,31246.49,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13338.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13338.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13338.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17339.93,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8216.86,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13871.95,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8545.54,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,13338.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12671.49,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16433.73,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13338.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17339.93,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13338.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17339.93,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11329.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11329.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11329.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14728.34,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5855.69,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11782.67,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6089.92,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,11329.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10763.02,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11711.38,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11329.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14728.34,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11329.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,14728.34,
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,21352.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21352.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21352.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27758.37,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7247.07,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22206.69,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7536.96,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,21352.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20284.96,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14494.15,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,21352.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27758.37,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21352.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,27758.37,
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11437.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11437.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11437.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14868.83,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6838.2,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11895.06,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7111.73,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,11437.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10865.68,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13676.4,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11437.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14868.83,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11437.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,14868.83,
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8850.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8850.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8850.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11505.18,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4697.51,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9204.15,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4885.42,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,8850.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8407.63,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9395.03,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8850.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11505.18,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8850.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11505.18,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,20167.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20167.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20167.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26218.08,130,MS-DRG,,Case rate,130% Medicare MS-DRG,12222.62,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20974.46,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12711.53,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,20167.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19159.36,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,24445.24,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,20167.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26218.08,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20167.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,26218.08,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12662.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12662.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12662.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16461.82,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7756.5,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13169.46,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8066.77,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,12662.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12029.79,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,15513,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12662.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16461.82,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12662.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16461.82,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9908.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9908.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9908.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12881.23,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4825.32,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10304.99,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5018.34,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,9908.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9413.21,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9650.65,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9908.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12881.23,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9908.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12881.23,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,24334.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24334.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24334.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31634.43,130,MS-DRG,,Case rate,130% Medicare MS-DRG,13520.72,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25307.55,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14061.56,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,24334.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23117.47,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,27041.45,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,24334.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31634.43,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,24334.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,31634.43,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14746.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14746.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14746.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19170.52,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9685.78,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15336.41,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10073.22,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,14746.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14009.22,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,19371.57,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14746.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19170.52,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14746.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,19371.57,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11923.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11923.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11923.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15501.08,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6843.65,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12400.87,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7117.4,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,11923.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11327.71,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13687.3,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11923.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15501.08,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11923.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15501.08,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,35097.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35097.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35097.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,45626.23,130,MS-DRG,,Case rate,130% Medicare MS-DRG,21478.93,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36500.98,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22338.11,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,35097.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33342.25,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,42957.87,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,35097.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,45626.23,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,35097.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,45626.23,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,18553,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18553,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18553,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24118.9,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9928.68,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19295.12,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10325.84,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,18553,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17625.35,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,19857.37,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,18553,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24118.9,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18553,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,24118.9,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11276.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11276.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11276.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14659.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9077.62,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11727.31,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9440.73,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,11276.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10712.45,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,18155.24,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11276.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14659.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11276.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18155.24,
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14223.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14223.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14223.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18490.76,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8586.36,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14792.61,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8929.82,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,14223.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13512.48,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,17172.73,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14223.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18490.76,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14223.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18490.76,
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8949.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8949.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8949.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11634.31,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6986,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9307.45,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7265.44,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8949.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8502,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13972,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8949.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11634.31,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8949.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13972,
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7005.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7005.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7005.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9107.45,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3524.2,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7285.96,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3665.17,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7005.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6655.44,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7048.39,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7005.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9107.45,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7005.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9107.45,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14984.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14984.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14984.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19479.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10397.53,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15583.52,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10813.44,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,14984.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14234.94,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,20795.05,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14984.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19479.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14984.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20795.05,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9378.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9378.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9378.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12192.18,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6096.77,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9753.74,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6340.65,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9378.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8909.67,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12193.55,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9378.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12192.18,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9378.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12193.55,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6789.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6789.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6789.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8826.45,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4783.53,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7061.16,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4974.87,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6789.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6450.1,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9567.06,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6789.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8826.45,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6789.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9567.06,
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,17775.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17775.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17775.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23108.55,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10180.67,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18486.84,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10587.91,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,17775.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16887.02,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,20361.34,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,17775.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23108.55,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17775.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,23108.55,
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10618.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10618.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10618.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13803.75,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7839.49,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11043,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8153.07,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,10618.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10087.36,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,15678.97,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10618.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13803.75,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10618.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15678.97,
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8179.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8179.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8179.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10633.29,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4881.05,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8506.63,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5076.3,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8179.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7770.48,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9762.11,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8179.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10633.29,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8179.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10633.29,
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15322.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15322.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15322.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19919.5,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9849.94,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15935.6,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10243.94,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,15322.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14556.56,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,19699.88,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15322.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19919.5,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15322.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,19919.5,
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8913.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8913.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8913.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11587.84,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5975.02,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9270.27,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6214.02,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8913.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8468.03,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11950.04,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8913.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11587.84,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8913.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11950.04,
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6127.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6127.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6127.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7965.92,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4804.12,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6372.74,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4996.29,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6127.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5821.25,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9608.25,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6127.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7965.92,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6127.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9608.25,
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,16579.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16579.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16579.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21553.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7703.2,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17243.03,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8011.33,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,16579.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15750.85,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,15406.39,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,16579.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21553.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16579.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,21553.79,
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9622.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9622.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9622.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12509.33,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5885.37,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10007.46,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6120.79,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9622.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9141.43,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11770.74,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9622.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12509.33,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9622.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12509.33,
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7112.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7112.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7112.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9245.87,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4412.82,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7396.7,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4589.33,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7112.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6756.6,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8825.63,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7112.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9245.87,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7112.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9245.87,
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12206.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12206.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12206.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15868.84,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6744.31,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12695.07,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7014.09,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,12206.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11596.46,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13488.62,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12206.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15868.84,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12206.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15868.84,
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8054.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8054.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8054.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10471.08,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4838.05,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8376.87,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5031.57,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8054.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7651.95,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9676.09,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8054.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10471.08,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8054.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10471.08,
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13547.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13547.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13547.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17611.62,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6798.22,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14089.3,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7070.15,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,13547.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12870.03,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13596.44,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13547.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17611.62,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13547.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17611.62,
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8816.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8816.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8816.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11461.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6361.48,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9169.43,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6615.94,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8816.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8375.92,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12722.96,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8816.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11461.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8816.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12722.96,
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6532.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6532.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6532.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8491.74,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5131.83,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6793.39,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5337.11,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6532.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6205.5,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10263.66,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6532.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8491.74,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6532.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10263.66,
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12646.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12646.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12646.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16440.13,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7472.41,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13152.1,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7771.31,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,12646.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12013.94,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14944.82,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12646.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16440.13,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12646.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16440.13,
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7424.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7424.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7424.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9651.88,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5086.4,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7721.5,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5289.86,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7424.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7053.29,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10172.8,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7424.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9651.88,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7424.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10172.8,
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,5537.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5537.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5537.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7199.39,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3563.57,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5759.51,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3706.11,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,5537.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5261.09,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7127.14,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,5537.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7199.39,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5537.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,7199.39,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11233.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11233.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11233.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14603.34,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6688.58,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11682.67,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6956.13,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,11233.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10671.67,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13377.16,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11233.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14603.34,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11233.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,14603.34,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7338.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7338.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7338.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9540.3,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4510.95,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7632.24,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4691.39,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7338.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6971.76,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9021.89,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7338.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9540.3,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7338.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9540.3,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13966.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13966.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13966.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18156.05,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7598.4,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14524.84,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7902.34,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,13966.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13267.88,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,15196.81,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13966.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18156.05,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13966.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18156.05,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8541.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8541.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8541.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11103.33,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6012.58,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8882.66,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6253.08,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8541.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8113.97,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12025.15,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8541.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11103.33,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8541.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12025.15,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6241.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6241.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6241.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8113.64,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4068.76,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6490.91,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4231.51,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6241.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5929.2,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8137.51,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6241.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8113.64,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6241.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,8137.51,
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,18948.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18948.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18948.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24633.36,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19706.69,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18948.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18001.3,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,18948.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24633.36,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18948.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,24633.36,
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13121.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13121.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13121.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17057.9,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13646.32,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13121.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12465.39,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,13121.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17057.9,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13121.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17057.9,
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9941.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9941.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9941.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12923.59,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10338.87,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9941.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9444.16,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,9941.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12923.59,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9941.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12923.59,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,44843.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,44843.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,44843.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,58296.75,130,MS-DRG,,Case rate,130% Medicare MS-DRG,23615.99,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46637.4,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,24560.64,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,44843.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42601.47,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,47231.97,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,44843.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,58296.75,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,44843.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,58296.75,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,24040.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24040.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24040.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31253.22,130,MS-DRG,,Case rate,130% Medicare MS-DRG,16957.09,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25002.58,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17635.38,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,24040.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22838.89,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,33914.17,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,24040.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31253.22,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,24040.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,33914.17,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,18189.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18189.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18189.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23645.75,130,MS-DRG,,Case rate,130% Medicare MS-DRG,12475.22,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18916.6,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12974.23,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,18189.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17279.59,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,24950.43,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,18189.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23645.75,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18189.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,24950.43,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,30674.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30674.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30674.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39877.24,130,MS-DRG,,Case rate,130% Medicare MS-DRG,18694.95,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31901.79,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,19442.76,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,30674.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29141.06,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,37389.91,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,30674.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39877.24,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,30674.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,39877.24,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,16649.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16649.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16649.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21644.71,130,MS-DRG,,Case rate,130% Medicare MS-DRG,12060.89,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17315.77,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12543.33,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,16649.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15817.29,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,24121.78,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,16649.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21644.71,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16649.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,24121.78,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13533.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13533.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13533.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17594.06,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8501.56,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14075.25,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8841.63,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,13533.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12857.2,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,17003.12,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13533.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17594.06,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13533.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17594.06,
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,25256.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25256.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25256.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32833.83,130,MS-DRG,,Case rate,130% Medicare MS-DRG,22491.13,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26267.06,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,23390.79,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,25256.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23993.95,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,44982.25,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,25256.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32833.83,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,25256.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,44982.25,
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,17514.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17514.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17514.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22768.67,130,MS-DRG,,Case rate,130% Medicare MS-DRG,11487.25,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18214.93,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11946.75,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,17514.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16638.64,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,22974.51,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,17514.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22768.67,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17514.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,22974.51,
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13092.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13092.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13092.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17019.67,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8480.36,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13615.73,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8819.58,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,13092.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12437.45,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16960.72,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13092.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17019.67,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13092.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17019.67,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,29109.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29109.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29109.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37842.1,130,MS-DRG,,Case rate,130% Medicare MS-DRG,22082.86,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30273.68,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22966.19,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,29109.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27653.84,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,44165.71,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,29109.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37842.1,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,29109.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,44165.71,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,16796.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16796.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16796.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21835.83,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10681.62,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17468.66,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11108.89,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,16796.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15956.95,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,21363.24,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,16796.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21835.83,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16796.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,21835.83,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11737.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11737.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11737.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15259.34,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5685.48,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12207.47,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5912.9,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,11737.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11151.05,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11370.95,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11737.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15259.34,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11737.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15259.34,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,19514.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19514.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19514.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25368.9,130,MS-DRG,,Case rate,130% Medicare MS-DRG,13507.4,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20295.12,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14047.7,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,19514.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18538.81,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,27014.79,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,19514.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25368.9,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,19514.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,27014.79,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14086.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14086.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14086.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18312.03,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9163.03,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14649.63,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9529.56,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,14086.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13381.87,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,18326.06,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14086.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18312.03,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14086.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18326.06,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11531.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11531.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11531.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14990.74,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7199.22,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11992.59,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7487.19,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,11531.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10954.77,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14398.44,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11531.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14990.74,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11531.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,14990.74,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,26531.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26531.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26531.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34490.85,130,MS-DRG,,Case rate,130% Medicare MS-DRG,20683.6,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27592.68,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21510.96,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,26531.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25204.85,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,41367.2,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,26531.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34490.85,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,26531.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,41367.2,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14681.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14681.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14681.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19085.81,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8248.97,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15268.65,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8578.93,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,14681.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13947.32,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16497.93,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14681.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19085.81,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14681.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,19085.81,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12308.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12308.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12308.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16001.06,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7314.31,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12800.85,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7606.89,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,12308.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11693.08,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14628.62,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12308.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16001.06,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12308.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16001.06,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,32174.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32174.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32174.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41826.62,130,MS-DRG,,Case rate,130% Medicare MS-DRG,19517.55,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33461.29,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20298.26,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,32174.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30565.6,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,39035.1,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,32174.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41826.62,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,32174.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,41826.62,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,18035.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18035.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18035.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23446.37,130,MS-DRG,,Case rate,130% Medicare MS-DRG,11114.12,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18757.1,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11558.69,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,18035.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17133.89,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,22228.24,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,18035.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23446.37,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18035.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,23446.37,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13825.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13825.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13825.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17973.2,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10923.31,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14378.56,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11360.25,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,13825.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13134.26,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,21846.62,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13825.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17973.2,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13825.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,21846.62,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,16321.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16321.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16321.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21218.04,130,MS-DRG,,Case rate,130% Medicare MS-DRG,11349.75,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16974.43,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11803.75,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,16321.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15505.49,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,22699.5,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,16321.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21218.04,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16321.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,22699.5,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9288.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9288.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9288.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12075.44,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5711.52,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9660.35,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5939.99,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9288.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8824.36,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11423.04,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9288.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12075.44,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9288.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12075.44,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6416.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6416.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6416.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8340.92,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3973.65,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6672.73,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4132.6,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6416.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6095.29,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7947.31,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6416.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8340.92,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6416.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,8340.92,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15081.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15081.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15081.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19605.44,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8665.72,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15684.35,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9012.35,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,15081.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14327.05,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,17331.43,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15081.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19605.44,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15081.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,19605.44,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9842.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9842.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9842.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12795.48,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6380.26,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10236.39,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6635.47,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9842.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9350.55,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12760.52,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9842.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12795.48,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9842.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12795.48,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7700.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7700.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7700.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10010.34,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5011.29,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8008.27,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5211.74,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7700.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7315.25,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10022.57,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7700.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10010.34,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7700.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10022.57,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14357.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14357.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14357.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18664.31,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10719.18,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14931.45,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11147.95,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,14357.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13639.3,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,21438.35,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14357.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18664.31,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14357.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,21438.35,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7891.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7891.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7891.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10259.31,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5443.18,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8207.45,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5660.91,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7891.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7497.19,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10886.36,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7891.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10259.31,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7891.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10886.36,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,5987.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5987.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5987.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7784.09,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3985.77,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6227.27,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4145.2,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,5987.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5688.37,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7971.54,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,5987.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7784.09,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5987.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,7971.54,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15623.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15623.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15623.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20311.01,130,MS-DRG,,Case rate,130% Medicare MS-DRG,11011.14,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16248.8,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11451.59,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,15623.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14842.66,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,22022.28,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15623.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20311.01,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15623.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,22022.28,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8657.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8657.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8657.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11254.15,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6634.06,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9003.32,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6899.43,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8657.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8224.19,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13268.13,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8657.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11254.15,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8657.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13268.13,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6775.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6775.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6775.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8807.86,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4126.91,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7046.29,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4291.99,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6775.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6436.52,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8253.81,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6775.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8807.86,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6775.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,8807.86,
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14074.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14074.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14074.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18296.55,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9256.31,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14637.24,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9626.57,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,14074.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13370.56,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,18512.63,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14074.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18296.55,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14074.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18512.63,
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9732.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9732.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9732.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12651.89,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6724.32,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10121.51,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6993.3,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9732.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9245.61,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13448.64,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9732.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12651.89,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9732.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13448.64,
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7465.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7465.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7465.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9704.57,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4267.44,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7763.65,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4438.14,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7465.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7091.8,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8534.88,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7465.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9704.57,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7465.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9704.57,
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH MCC,453,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,71514.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,71514.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,71514.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,92968.41,130,MS-DRG,,Case rate,130% Medicare MS-DRG,55304.67,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74374.73,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,57516.89,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,71514.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,67938.45,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,110609.34,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,71514.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,92968.41,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,71514.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,110609.34,
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,454,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,49699.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49699.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49699.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,64609.81,130,MS-DRG,,Case rate,130% Medicare MS-DRG,32304.72,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51687.84,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,33596.93,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,49699.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47214.86,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,64609.44,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,49699.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,64609.81,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,49699.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,64609.81,
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,455,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,37694.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37694.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37694.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49003.32,130,MS-DRG,,Case rate,130% Medicare MS-DRG,29733.96,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39202.65,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,30923.34,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,37694.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35810.12,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,59467.92,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,37694.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49003.32,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,37694.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,59467.92,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,68081.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,68081.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,68081.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,88505.6,130,MS-DRG,,Case rate,130% Medicare MS-DRG,67885.28,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70804.48,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,70600.74,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,68081.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,64677.17,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,135770.56,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,68081.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,88505.6,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,68081.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,135770.56,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,49374.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49374.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49374.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,64186.25,130,MS-DRG,,Case rate,130% Medicare MS-DRG,47625.1,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51349,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,49530.13,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,49374.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46905.34,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,95250.19,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,49374.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,64186.25,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,49374.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,95250.19,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,37102.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37102.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37102.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,48232.65,130,MS-DRG,,Case rate,130% Medicare MS-DRG,45701.27,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38586.12,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,47529.35,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,37102.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35246.94,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,91402.53,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,37102.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,48232.65,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,37102.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,91402.53,
SPINAL FUSION EXCEPT CERVICAL WITH MCC,459,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,53800.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,53800.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,53800.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,69940.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,54508.12,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55952.32,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,56688.48,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,53800.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,51110.29,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,109016.24,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,53800.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,69940.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,53800.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,109016.24,
SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,460,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,30163.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30163.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30163.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39212.98,130,MS-DRG,,Case rate,130% Medicare MS-DRG,24342.87,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31370.38,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,25316.6,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,30163.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28655.64,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,48685.75,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,30163.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39212.98,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,30163.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,48685.75,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,55279.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,55279.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,55279.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,71863.97,130,MS-DRG,,Case rate,130% Medicare MS-DRG,24198.1,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57491.18,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,25166.04,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,55279.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52515.98,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,48396.2,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,55279.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,71863.97,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,55279.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,71863.97,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,23714.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23714.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23714.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30828.64,130,MS-DRG,,Case rate,130% Medicare MS-DRG,24198.1,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24662.91,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,25166.04,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,23714.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22528.62,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,48396.2,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,23714.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30828.64,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,23714.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,48396.2,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,46103.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46103.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46103.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,59934.16,130,MS-DRG,,Case rate,130% Medicare MS-DRG,34991.78,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47947.33,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,36391.48,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,46103.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43798.04,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,69983.57,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,46103.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,59934.16,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,46103.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,69983.57,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,24946.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24946.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24946.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32430.92,130,MS-DRG,,Case rate,130% Medicare MS-DRG,18238.83,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25944.73,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18968.4,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,24946.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23699.52,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,36477.66,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,24946.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32430.92,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,24946.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,36477.66,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15962.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15962.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15962.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20751.11,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8888.63,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16600.89,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9244.18,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,15962.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15164.27,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,17777.26,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15962.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20751.11,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15962.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20751.11,
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,42311.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42311.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42311.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,55005.41,130,MS-DRG,,Case rate,130% Medicare MS-DRG,19670.8,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44004.32,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20457.65,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,42311.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40196.26,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,39341.6,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,42311.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,55005.41,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,42311.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,55005.41,
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,28800.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28800.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28800.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37440.25,130,MS-DRG,,Case rate,130% Medicare MS-DRG,17832.38,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29952.2,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18545.69,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,28800.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27360.18,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,35664.76,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,28800.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37440.25,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,28800.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,37440.25,
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,22310.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22310.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22310.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29003.21,130,MS-DRG,,Case rate,130% Medicare MS-DRG,14314.24,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23202.57,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14886.82,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,22310.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21194.65,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,28628.48,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,22310.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29003.21,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22310.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,29003.21,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,27556.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27556.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27556.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35823.49,130,MS-DRG,,Case rate,130% Medicare MS-DRG,17445.31,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28658.79,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18143.14,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,27556.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26178.7,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,34890.62,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,27556.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35823.49,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,27556.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,35823.49,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,16049.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16049.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16049.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20863.71,130,MS-DRG,,Case rate,130% Medicare MS-DRG,13133.05,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16690.97,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13658.38,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,16049.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15246.56,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,26266.1,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,16049.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20863.71,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16049.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,26266.1,
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,40185.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40185.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40185.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52240.94,130,MS-DRG,,Case rate,130% Medicare MS-DRG,20480.07,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41792.75,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21299.29,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,40185.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38176.07,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,40960.14,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,40185.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52240.94,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,40185.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,52240.94,
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,24581.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24581.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24581.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31955.7,130,MS-DRG,,Case rate,130% Medicare MS-DRG,15820.72,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25564.56,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16453.56,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,24581.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23352.24,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,31641.43,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,24581.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31955.7,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,24581.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,31955.7,
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,20649.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20649.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20649.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26844.12,130,MS-DRG,,Case rate,130% Medicare MS-DRG,12268.05,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21475.29,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12758.78,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,20649.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19616.85,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,24536.1,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,20649.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26844.12,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20649.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,26844.12,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,35288.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35288.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35288.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,45875.19,130,MS-DRG,,Case rate,130% Medicare MS-DRG,21170.01,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36700.15,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22016.82,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,35288.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33524.18,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,42340.01,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,35288.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,45875.19,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,35288.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,45875.19,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,18138.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18138.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18138.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23580.66,130,MS-DRG,,Case rate,130% Medicare MS-DRG,13404.42,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18864.53,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13940.61,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,18138.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17232.02,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,26808.84,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,18138.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23580.66,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18138.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,26808.84,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10448.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10448.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10448.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13582.67,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5810.26,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10866.14,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6042.67,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,10448.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9925.8,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11620.52,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10448.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13582.67,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10448.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13582.67,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,27868.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27868.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27868.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36228.45,130,MS-DRG,,Case rate,130% Medicare MS-DRG,17041.89,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28982.76,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17723.58,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,27868.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26474.64,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,34083.78,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,27868.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36228.45,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,27868.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,36228.45,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,20038.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20038.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20038.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26049.69,130,MS-DRG,,Case rate,130% Medicare MS-DRG,13635.81,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20839.75,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14181.25,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,20038.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19036.31,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,27271.63,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,20038.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26049.69,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20038.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,27271.63,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15908.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15908.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15908.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20680.86,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10247.91,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16544.68,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10657.83,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,15908.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15112.93,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,20495.82,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15908.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20680.86,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15908.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20680.86,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,24529.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24529.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24529.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31888.56,130,MS-DRG,,Case rate,130% Medicare MS-DRG,23307.06,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25510.85,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,24239.36,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,24529.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23303.18,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,46614.12,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,24529.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31888.56,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,24529.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,46614.12,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,17584.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17584.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17584.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22859.58,130,MS-DRG,,Case rate,130% Medicare MS-DRG,14173.1,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18287.66,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14740.04,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,17584.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16705.08,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,28346.21,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,17584.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22859.58,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17584.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,28346.21,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13718.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13718.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13718.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17833.73,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10044.99,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14266.98,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10446.79,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,13718.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13032.34,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,20089.97,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13718.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17833.73,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13718.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20089.97,
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,20836.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20836.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20836.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27087.91,130,MS-DRG,,Case rate,130% Medicare MS-DRG,13988.35,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21670.32,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14547.9,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,20836.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19795.01,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,27976.71,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,20836.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27087.91,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20836.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,27976.71,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,27272.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27272.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27272.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35453.67,130,MS-DRG,,Case rate,130% Medicare MS-DRG,12322.57,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28362.93,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12815.48,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,27272.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25908.45,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,24645.14,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,27272.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35453.67,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,27272.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,35453.67,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,17055.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17055.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17055.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22171.57,130,MS-DRG,,Case rate,130% Medicare MS-DRG,11430.31,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17737.25,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11887.53,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,17055.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16202.3,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,22860.63,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,17055.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22171.57,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17055.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,22860.63,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13372.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13372.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13372.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17384.37,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6270.62,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13907.49,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6521.45,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,13372.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12703.96,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12541.24,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13372.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17384.37,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13372.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17384.37,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,17836.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17836.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17836.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23187.06,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9154.55,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18549.65,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9520.74,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,17836.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16944.39,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,18309.1,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,17836.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23187.06,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17836.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,23187.06,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10931.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10931.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10931.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14210.78,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8176.88,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11368.62,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8503.97,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,10931.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10384.8,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16353.77,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10931.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14210.78,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10931.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16353.77,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,28607.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28607.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28607.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37190.23,130,MS-DRG,,Case rate,130% Medicare MS-DRG,19245.57,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29752.18,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20015.41,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,28607.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27177.48,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,38491.14,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,28607.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37190.23,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,28607.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,38491.14,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,20181.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20181.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20181.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26235.64,130,MS-DRG,,Case rate,130% Medicare MS-DRG,12965.86,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20988.51,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13484.51,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,20181.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19172.2,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,25931.73,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,20181.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26235.64,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20181.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,26235.64,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15949.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15949.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15949.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20734.58,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9490.73,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16587.67,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9870.37,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,15949.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15152.2,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,18981.47,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15949.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20734.58,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15949.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20734.58,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,29554.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29554.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29554.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38420.62,130,MS-DRG,,Case rate,130% Medicare MS-DRG,15537.84,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30736.49,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16159.36,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,29554.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28076.6,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,31075.67,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,29554.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38420.62,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,29554.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,38420.62,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,16889.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16889.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16889.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21956.68,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8712.96,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17565.34,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9061.49,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,16889.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16045.26,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,17425.93,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,16889.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21956.68,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16889.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,21956.68,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12438.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12438.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12438.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16170.49,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6936.93,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12936.39,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7214.42,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,12438.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11816.9,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13873.87,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12438.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16170.49,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12438.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16170.49,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,21844.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21844.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21844.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28397.84,130,MS-DRG,,Case rate,130% Medicare MS-DRG,11267.37,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22718.27,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11718.07,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,21844.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20752.27,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,22534.74,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,21844.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28397.84,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21844.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,28397.84,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11345.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11345.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11345.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14749.01,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6045.89,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11799.21,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6287.73,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,11345.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10778.12,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12091.78,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11345.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14749.01,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11345.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,14749.01,
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,26865.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26865.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26865.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34924.72,130,MS-DRG,,Case rate,130% Medicare MS-DRG,14051.35,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27939.78,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14613.41,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,26865.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25521.91,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,28102.7,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,26865.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34924.72,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,26865.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,34924.72,
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14888.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14888.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14888.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19355.43,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10751.28,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15484.34,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11181.34,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,14888.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14144.35,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,21502.56,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14888.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19355.43,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14888.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,21502.56,
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12083.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12083.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12083.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15708.72,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7992.13,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12566.98,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8311.82,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,12083.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11479.45,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,15984.27,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12083.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15708.72,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12083.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15984.27,
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,22407.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22407.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22407.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29130.28,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10428.42,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23304.23,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10845.56,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,22407.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21287.51,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,20856.84,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,22407.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29130.28,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22407.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,29130.28,
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14820.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14820.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14820.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19266.59,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9086.1,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15413.27,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9449.55,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,14820.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14079.43,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,18172.2,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14820.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19266.59,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14820.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,19266.59,
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14650.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14650.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14650.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19045.51,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8763.24,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15236.41,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9113.78,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,14650.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13917.87,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,17526.48,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14650.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19045.51,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14650.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,19045.51,
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12718.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12718.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12718.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16534.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6385.11,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13227.31,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6640.51,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,12718.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12082.64,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12770.21,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12718.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16534.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12718.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16534.14,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,18035.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18035.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18035.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23446.37,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9064.29,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18757.1,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9426.87,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,18035.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17133.89,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,18128.59,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,18035.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23446.37,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18035.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,23446.37,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12491.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12491.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12491.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16238.68,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7640.2,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12990.94,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7945.81,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,12491.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11866.73,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,15280.4,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12491.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16238.68,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12491.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16238.68,
ARTHROSCOPY,509,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11951.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11951.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11951.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15537.24,130,MS-DRG,,Case rate,130% Medicare MS-DRG,12486.12,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12429.79,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12985.57,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,11951.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11354.13,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,24972.24,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11951.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15537.24,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11951.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,24972.24,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,22715.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22715.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22715.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29530.07,130,MS-DRG,,Case rate,130% Medicare MS-DRG,12935.58,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23624.06,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13453.01,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,22715.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21579.67,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,25871.16,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,22715.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29530.07,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22715.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,29530.07,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,16939.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16939.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16939.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22021.77,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9500.43,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17617.41,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9880.45,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,16939.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16092.83,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,19000.85,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,16939.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22021.77,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16939.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,22021.77,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13920.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13920.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13920.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18096.13,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6259.11,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14476.9,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6509.48,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,13920.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13224.1,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12518.22,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13920.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18096.13,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13920.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18096.13,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13977.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13977.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13977.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18170.5,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8025.45,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14536.4,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8346.47,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,13977.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13278.44,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16050.9,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13977.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18170.5,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13977.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18170.5,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9372.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9372.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9372.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12183.91,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6594.09,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9747.13,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6857.85,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,9372.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8903.63,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13188.17,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9372.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12183.91,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9372.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13188.17,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,26219.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26219.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26219.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34084.84,130,MS-DRG,,Case rate,130% Medicare MS-DRG,22065.29,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27267.87,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22947.92,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,26219.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24908.15,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,44130.58,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,26219.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34084.84,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,26219.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,44130.58,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,17313.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17313.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17313.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22507.32,130,MS-DRG,,Case rate,130% Medicare MS-DRG,13180.9,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18005.85,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13708.15,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,17313.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16447.65,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,26361.8,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,17313.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22507.32,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17313.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,26361.8,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12971.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12971.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12971.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16862.65,130,MS-DRG,,Case rate,130% Medicare MS-DRG,12163.26,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13490.12,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12649.8,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,12971.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12322.71,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,24326.52,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12971.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16862.65,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12971.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,24326.52,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,30115.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30115.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30115.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39149.96,130,MS-DRG,,Case rate,130% Medicare MS-DRG,14299.1,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31319.96,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14871.07,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,30115.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28609.58,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,28598.2,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,30115.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39149.96,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,30115.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,39149.96,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,16739.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16739.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16739.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21761.43,130,MS-DRG,,Case rate,130% Medicare MS-DRG,12128.73,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17409.14,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12613.89,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,16739.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15902.58,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,24257.46,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,16739.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21761.43,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16739.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,24257.46,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12471.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12471.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12471.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16212.86,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6601.35,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12970.29,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6865.41,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,12471.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11847.86,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13202.71,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12471.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16212.86,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12471.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16212.86,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,24889.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24889.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24889.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32356.55,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25885.24,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,24889.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23645.17,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,24889.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32356.55,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,24889.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,32356.55,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,17880.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17880.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17880.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23244.92,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18595.94,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,17880.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16986.67,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,17880.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23244.92,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17880.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,23244.92,
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14059.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14059.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14059.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18277.95,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5509.81,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14622.36,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5730.21,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,14059.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13356.96,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11019.62,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14059.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18277.95,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14059.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18277.95,
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7532.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7532.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7532.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9792.38,130,MS-DRG,,Case rate,130% Medicare MS-DRG,2904.52,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7833.9,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3020.71,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7532.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7155.97,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,5809.05,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7532.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9792.38,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7532.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9792.38,
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11400.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11400.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11400.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14820.29,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5168.78,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11856.23,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5375.53,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,11400.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10830.21,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10337.56,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11400.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14820.29,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11400.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,14820.29,
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7350.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7350.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7350.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9555.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4410.39,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7644.63,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4586.81,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7350.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6983.08,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8820.79,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7350.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9555.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7350.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9555.79,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8780.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8780.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8780.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11414.27,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4151.14,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9131.42,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4317.18,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8780.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8341.2,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8302.27,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8780.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11414.27,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8780.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11414.27,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6730.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6730.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6730.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8750,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3119.56,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7000,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3244.35,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6730.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6394.23,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,6239.12,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6730.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8750,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6730.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,8750,
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,16865.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16865.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16865.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21924.66,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10894.23,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17539.72,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11330.01,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,16865.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16021.86,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,21788.47,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,16865.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21924.66,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16865.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,21924.66,
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11412.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11412.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11412.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14835.8,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7862.51,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11868.64,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8177.01,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,11412.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10841.54,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,15725.01,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11412.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14835.8,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11412.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15725.01,
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7913.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7913.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7913.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10287.21,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4404.34,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8229.77,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4580.51,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7913.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7517.58,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8808.67,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7913.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10287.21,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7913.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10287.21,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15588.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15588.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15588.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20264.53,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8906.2,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16211.62,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9262.45,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,15588.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14808.7,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,17812.39,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15588.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20264.53,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15588.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20264.53,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9763.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9763.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9763.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12692.17,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8685.71,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10153.74,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9033.14,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9763.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9275.05,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,17371.41,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9763.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12692.17,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9763.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17371.41,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7194.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7194.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7194.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9353.32,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3822.22,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7482.65,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3975.11,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7194.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6835.12,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7644.44,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7194.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9353.32,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7194.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9353.32,
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,20908.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20908.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20908.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27180.88,130,MS-DRG,,Case rate,130% Medicare MS-DRG,13756.36,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21744.7,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14306.62,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,20908.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19862.95,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,27512.71,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,20908.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27180.88,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20908.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,27512.71,
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10626.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10626.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10626.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13814.07,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7200.43,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11051.26,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7488.45,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,10626.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10094.9,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14400.86,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10626.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13814.07,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10626.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,14400.86,
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7638.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7638.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7638.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9929.76,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4859.25,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7943.81,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5053.62,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7638.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7256.37,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9718.49,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7638.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9929.76,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7638.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9929.76,
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,16590.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16590.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16590.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21567.21,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8119.94,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17253.77,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8444.75,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,16590.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15760.65,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16239.89,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,16590.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21567.21,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16590.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,21567.21,
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10681.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10681.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10681.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13885.37,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8119.94,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11108.29,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8444.75,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,10681.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10147,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16239.89,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10681.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13885.37,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10681.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16239.89,
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8593.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8593.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8593.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11171.51,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4582.42,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8937.21,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4765.72,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8593.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8163.8,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9164.85,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8593.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11171.51,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8593.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11171.51,
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14620.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14620.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14620.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19006.26,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6718.26,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15205.01,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6987,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,14620.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13889.19,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13436.52,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14620.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19006.26,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14620.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,19006.26,
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8774.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8774.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8774.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11407.05,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5462.56,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9125.64,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5681.07,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8774.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8335.92,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10925.13,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8774.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11407.05,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8774.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11407.05,
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11835.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11835.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11835.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15386.41,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5155.45,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12309.13,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5361.67,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,11835.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11243.92,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10310.91,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11835.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15386.41,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11835.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15386.41,
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7626.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7626.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7626.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9914.27,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4826.54,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7931.41,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5019.6,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7626.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7245.04,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9653.07,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7626.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9914.27,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7626.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9914.27,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12213.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12213.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12213.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15877.11,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6923.61,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12701.69,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7200.56,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,12213.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11602.5,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13847.22,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12213.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15877.11,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12213.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15877.11,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7647.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7647.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7647.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9941.11,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4583.03,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7952.89,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4766.35,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7647.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7264.66,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9166.06,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7647.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9941.11,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7647.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9941.11,
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13467.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13467.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13467.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17507.3,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6008.34,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14005.84,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6248.67,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,13467.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12793.79,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12016.67,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13467.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17507.3,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13467.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17507.3,
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8076.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8076.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8076.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10499,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4721.14,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8399.2,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4909.99,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8076.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7672.34,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9442.28,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8076.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10499,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8076.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10499,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15801.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15801.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15801.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20541.38,130,MS-DRG,,Case rate,130% Medicare MS-DRG,17544.05,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16433.1,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18245.82,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,15801.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15011.01,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,35088.1,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15801.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20541.38,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15801.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,35088.1,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10092.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10092.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10092.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13119.87,130,MS-DRG,,Case rate,130% Medicare MS-DRG,12277.74,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10495.9,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12768.86,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,10092.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9587.6,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,24555.49,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10092.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13119.87,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10092.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,24555.49,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7295.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7295.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7295.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9484.53,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9079.44,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7587.62,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9442.62,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7295.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6931,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,18158.87,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7295.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9484.53,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7295.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18158.87,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13180.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13180.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13180.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17134.34,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5862.96,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13707.47,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6097.48,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,13180.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12521.25,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11725.91,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13180.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17134.34,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13180.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17134.34,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8212.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8212.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8212.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10676.67,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5188.16,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8541.33,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5395.69,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8212.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7802.18,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10376.33,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8212.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10676.67,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8212.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10676.67,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13507.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13507.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13507.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17559.96,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6869.7,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14047.97,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7144.49,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,13507.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12832.28,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13739.39,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13507.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17559.96,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13507.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17559.96,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9037.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9037.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9037.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11749,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6869.7,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9399.2,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7144.49,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9037.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8585.81,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13739.39,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9037.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11749,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9037.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13739.39,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7059.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7059.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7059.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9177.69,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3516.93,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7342.15,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3657.61,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7059.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6706.77,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7033.85,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7059.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9177.69,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7059.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9177.69,
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,24317.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24317.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24317.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31612.74,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9932.32,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25290.19,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10329.62,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,24317.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23101.62,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,19864.64,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,24317.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31612.74,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,24317.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,31612.74,
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14540.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14540.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14540.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18902.95,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7380.94,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15122.36,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7676.18,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,14540.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13813.69,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14761.88,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14540.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18902.95,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14540.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18902.95,
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10151.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10151.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10151.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13197.34,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5503.75,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10557.87,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5723.91,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,10151.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9644.21,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11007.51,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10151.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13197.34,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10151.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13197.34,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,50508.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,50508.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,50508.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,65661.45,130,MS-DRG,,Case rate,130% Medicare MS-DRG,16792.32,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52529.16,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17464.03,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,50508.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47983.37,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,33584.65,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,50508.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,65661.45,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,50508.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,65661.45,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,28160.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28160.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28160.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36608.62,130,MS-DRG,,Case rate,130% Medicare MS-DRG,13225.12,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29286.9,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13754.14,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,28160.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26752.46,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,26450.24,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,28160.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36608.62,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,28160.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,36608.62,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,17354.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17354.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17354.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22561.03,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8686.92,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18048.83,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9034.4,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,17354.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16486.91,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,17373.83,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,17354.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22561.03,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17354.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,22561.03,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,46257.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46257.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46257.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,60134.57,130,MS-DRG,,Case rate,130% Medicare MS-DRG,30903.64,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48107.65,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,32139.81,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,46257.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43944.49,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,61807.29,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,46257.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,60134.57,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,46257.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,61807.29,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,22147.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22147.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22147.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28791.44,130,MS-DRG,,Case rate,130% Medicare MS-DRG,13771.5,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23033.15,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14322.37,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,22147.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21039.9,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,27543,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,22147.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28791.44,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22147.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,28791.44,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13893.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13893.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13893.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18062.04,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9081.86,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14449.64,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9445.14,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,13893.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13199.19,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,18163.72,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13893.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18062.04,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13893.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18163.72,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,27655.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27655.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27655.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35951.59,130,MS-DRG,,Case rate,130% Medicare MS-DRG,18567.14,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28761.27,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,19309.84,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,27655.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26272.32,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,37134.28,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,27655.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35951.59,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,27655.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,37134.28,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14975.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14975.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14975.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19468.03,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8353.15,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15574.43,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8687.29,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,14975.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14226.64,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16706.31,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14975.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19468.03,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14975.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,19468.03,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11797.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11797.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11797.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15336.82,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5957.45,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12269.45,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6195.75,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,11797.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11207.67,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11914.91,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11797.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15336.82,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11797.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15336.82,
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14933.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14933.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14933.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19413.29,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9309.62,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15530.63,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9682.01,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,14933.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14186.64,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,18619.24,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14933.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19413.29,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14933.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,19413.29,
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13189.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13189.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13189.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17146.75,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8731.14,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13717.4,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9080.39,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,13189.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12530.32,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,17462.27,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13189.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17146.75,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13189.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17462.27,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,16660.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16660.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16660.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21658.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10366.03,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17326.51,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10780.68,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,16660.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15827.1,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,20732.06,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,16660.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21658.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16660.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,21658.14,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14477.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14477.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14477.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18821.34,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9296.29,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15057.07,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9668.15,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,14477.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13754.05,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,18592.58,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14477.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18821.34,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14477.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18821.34,
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,17705.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17705.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17705.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23016.62,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8740.83,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18413.29,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9090.47,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,17705.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16819.84,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,17481.66,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,17705.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23016.62,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17705.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,23016.62,
SKIN ULCERS WITH CC,593,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10710.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10710.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10710.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13923.6,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6145.23,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11138.88,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6391.05,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,10710.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10174.94,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12290.46,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10710.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13923.6,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10710.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13923.6,
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7353,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7353,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7353,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9558.9,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3046.87,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7647.12,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3168.75,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7353,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6985.35,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,6093.74,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7353,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9558.9,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7353,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9558.9,
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,18379.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18379.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18379.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23893.68,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9014.02,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19114.94,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9374.58,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,18379.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17460.76,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,18028.03,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,18379.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23893.68,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18379.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,23893.68,
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9113.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9113.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9113.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11848.16,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5439.55,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9478.53,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5657.13,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9113.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8658.27,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10879.09,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9113.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11848.16,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9113.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11848.16,
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13814.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13814.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13814.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17958.73,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7440.91,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14366.99,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7738.55,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,13814.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13123.69,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14881.82,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13814.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17958.73,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13814.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17958.73,
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10622.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10622.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10622.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13808.93,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5629.75,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11047.14,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5854.94,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,10622.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10091.14,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11259.5,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10622.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13808.93,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10622.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13808.93,
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6442.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6442.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6442.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8375,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5629.75,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6700,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5854.94,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6442.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6120.19,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11259.5,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6442.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8375,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6442.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11259.5,
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9245.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9245.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9245.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12018.62,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5570.99,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9614.89,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5793.83,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9245.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8782.84,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11141.98,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9245.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12018.62,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9245.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12018.62,
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6130.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6130.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6130.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7969.01,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4165.07,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6375.21,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4331.67,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6130.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5823.51,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8330.14,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6130.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7969.01,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6130.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,8330.14,
CELLULITIS WITH MCC,602,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12916.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12916.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12916.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16791.39,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8272.59,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13433.11,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8603.5,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,12916.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12270.63,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16545.18,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12916.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16791.39,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12916.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16791.39,
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8126.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8126.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8126.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10564.07,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5351.71,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8451.26,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5565.78,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8126.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7719.9,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10703.43,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8126.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10564.07,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8126.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10703.43,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13065.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13065.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13065.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16984.55,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5889,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13587.64,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6124.57,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,13065.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12411.79,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11778.01,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13065.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16984.55,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13065.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16984.55,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8317.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8317.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8317.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10813.04,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4225.04,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8650.43,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4394.04,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8317.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7901.83,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8450.07,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8317.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10813.04,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8317.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10813.04,
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13697.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13697.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13697.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17806.87,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5539.49,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14245.49,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5761.08,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,13697.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13012.71,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11078.98,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13697.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17806.87,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13697.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17806.87,
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8196.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8196.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8196.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10654.98,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4198.38,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8523.99,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4366.32,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8196.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7786.33,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8396.77,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8196.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10654.98,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8196.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10654.98,
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,18994.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18994.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18994.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24693.27,130,MS-DRG,,Case rate,130% Medicare MS-DRG,15787.4,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19754.61,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16418.91,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,18994.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18045.08,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,31574.8,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,18994.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24693.27,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18994.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,31574.8,
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12786.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12786.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12786.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16621.94,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7766.19,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13297.55,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8076.85,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,12786.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12146.8,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,15532.39,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12786.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16621.94,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12786.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16621.94,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,32546.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32546.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32546.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42310.11,130,MS-DRG,,Case rate,130% Medicare MS-DRG,19658.08,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33848.09,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20444.42,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,32546.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30918.93,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,39316.16,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,32546.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42310.11,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,32546.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,42310.11,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,16865.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16865.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16865.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21925.7,130,MS-DRG,,Case rate,130% Medicare MS-DRG,11366.11,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17540.56,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11820.76,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,16865.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16022.62,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,22732.21,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,16865.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21925.7,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16865.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,22732.21,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10325.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10325.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10325.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13423.59,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8036.35,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10738.87,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8357.81,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,10325.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9809.55,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16072.71,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10325.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13423.59,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10325.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16072.71,
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,21776.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21776.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21776.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28310.02,130,MS-DRG,,Case rate,130% Medicare MS-DRG,16633.01,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22648.02,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17298.35,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,21776.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20688.09,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,33266.03,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,21776.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28310.02,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21776.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,33266.03,
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13986.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13986.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13986.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18182.91,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10696.16,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14546.32,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11124.01,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,13986.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13287.51,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,21392.31,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13986.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18182.91,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13986.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,21392.31,
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13153.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13153.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13153.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17099.23,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8604.54,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13679.38,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8948.72,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,13153.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12495.59,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,17209.07,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13153.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17099.23,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13153.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17209.07,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,31496.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31496.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31496.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40945.42,130,MS-DRG,,Case rate,130% Medicare MS-DRG,20050.6,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32756.34,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20852.64,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,31496.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29921.66,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,40101.2,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,31496.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40945.42,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,31496.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,40945.42,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15887.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15887.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15887.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20654,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10953.6,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16523.2,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11391.75,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,15887.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15093.31,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,21907.19,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15887.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20654,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15887.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,21907.19,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9952.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9952.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9952.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12938.04,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4394.64,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10350.43,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4570.43,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,9952.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9454.72,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8789.29,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9952.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12938.04,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9952.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12938.04,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,24309.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24309.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24309.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31602.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,11403.06,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25281.92,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11859.19,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,24309.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23094.06,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,22806.11,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,24309.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31602.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,24309.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,31602.4,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12951.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12951.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12951.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16836.83,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9639.14,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13469.47,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10024.71,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,12951.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12303.84,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,19278.28,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12951.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16836.83,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12951.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,19278.28,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10917.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10917.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10917.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14193.22,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7020.53,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11354.57,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7301.35,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,10917.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10371.97,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14041.05,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10917.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14193.22,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10917.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,14193.22,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,32997.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32997.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32997.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42896.88,130,MS-DRG,,Case rate,130% Medicare MS-DRG,14643.76,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34317.5,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15229.52,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,32997.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31347.72,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,29287.53,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,32997.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42896.88,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,32997.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,42896.88,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,19077.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19077.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19077.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24800.71,130,MS-DRG,,Case rate,130% Medicare MS-DRG,14643.76,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19840.57,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15229.52,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,19077.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18123.6,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,29287.53,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,19077.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24800.71,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,19077.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,29287.53,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12191.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12191.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12191.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15849.21,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7259.19,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12679.37,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7549.56,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,12191.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11582.12,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14518.38,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12191.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15849.21,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12191.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15849.21,
DIABETES WITH MCC,637,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12612.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12612.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12612.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16396.74,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8181.73,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13117.4,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8509,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,12612.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11982.24,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16363.46,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12612.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16396.74,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12612.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16396.74,
DIABETES WITH CC,638,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8243.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8243.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8243.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10715.94,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4775.05,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8572.75,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4966.05,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8243.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7830.88,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9550.1,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8243.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10715.94,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8243.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10715.94,
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6042.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6042.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6042.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7855.38,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3325.51,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6284.3,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3458.54,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6042.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5740.47,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,6651.03,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6042.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7855.38,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6042.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,7855.38,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11547.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11547.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11547.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15011.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5875.07,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12009.12,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6110.08,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,11547.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10969.87,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11750.14,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11547.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15011.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11547.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15011.4,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7305.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7305.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7305.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9496.9,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4499.44,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7597.52,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4679.42,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7305.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6940.04,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8998.87,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7305.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9496.9,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7305.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9496.9,
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11452.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11452.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11452.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14888.47,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5568.57,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11910.78,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5791.31,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,11452.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10880.04,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11137.14,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11452.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14888.47,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11452.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,14888.47,
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14168.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14168.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14168.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18419.49,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10324.23,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14735.59,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10737.21,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,14168.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13460.4,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,20648.47,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14168.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18419.49,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14168.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20648.47,
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9532.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9532.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9532.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12392.59,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5476.5,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9914.07,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5695.56,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9532.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9056.12,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10952.99,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9532.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12392.59,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9532.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12392.59,
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7142.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7142.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7142.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9285.13,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4210.5,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7428.11,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4378.92,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7142.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6785.29,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8421,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7142.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9285.13,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7142.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9285.13,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,36835.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36835.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36835.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47886.59,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8822.6,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38309.27,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9175.51,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,36835.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34994.05,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,17645.21,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,36835.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47886.59,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,36835.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,47886.59,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,28578.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28578.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28578.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37152.01,130,MS-DRG,,Case rate,130% Medicare MS-DRG,52081.53,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29721.61,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,54164.82,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,28578.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27149.55,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,104163.05,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,28578.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37152.01,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,28578.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,104163.05,
KIDNEY TRANSPLANT,652,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,24970.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24970.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24970.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32461.91,130,MS-DRG,,Case rate,130% Medicare MS-DRG,83675.71,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25969.53,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,87022.8,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,24970.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23722.17,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,167351.42,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,24970.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32461.91,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,24970.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,167351.42,
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,44115.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,44115.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,44115.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,57350.46,130,MS-DRG,,Case rate,130% Medicare MS-DRG,28950.13,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45880.37,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,30108.16,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,44115.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41909.95,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,57900.26,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,44115.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,57350.46,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,44115.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,57900.26,
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,22849.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22849.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22849.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29704.66,130,MS-DRG,,Case rate,130% Medicare MS-DRG,13261.47,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23763.73,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13791.93,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,22849.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21707.25,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,26522.93,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,22849.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29704.66,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22849.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,29704.66,
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,17845.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17845.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17845.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23199.48,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10929.37,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18559.58,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11366.55,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,17845.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16953.46,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,21858.73,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,17845.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23199.48,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17845.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,23199.48,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,26029.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26029.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26029.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33837.95,130,MS-DRG,,Case rate,130% Medicare MS-DRG,16486.43,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27070.36,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17145.89,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,26029.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24727.73,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,32972.85,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,26029.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33837.95,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,26029.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,33837.95,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15751,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15751,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15751,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20476.3,130,MS-DRG,,Case rate,130% Medicare MS-DRG,14404.5,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16381.04,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14980.69,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,15751,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14963.45,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,28808.99,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15751,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20476.3,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15751,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,28808.99,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12860.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12860.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12860.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16718.01,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10769.45,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13374.41,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11200.24,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,12860.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12217.01,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,21538.9,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12860.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16718.01,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12860.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,21538.9,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,21668.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21668.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21668.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28169.52,130,MS-DRG,,Case rate,130% Medicare MS-DRG,15227.09,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22535.61,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15836.19,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,21668.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20585.42,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,30454.18,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,21668.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28169.52,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21668.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,30454.18,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11791.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11791.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11791.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15328.55,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8319.23,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12262.84,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8652.01,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,11791.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11201.63,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16638.47,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11791.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15328.55,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11791.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16638.47,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9427.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9427.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9427.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12255.19,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7380.34,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9804.15,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7675.55,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,9427.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8955.72,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14760.67,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9427.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12255.19,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9427.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,14760.67,
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,24909.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24909.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24909.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32382.36,130,MS-DRG,,Case rate,130% Medicare MS-DRG,20768.4,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25905.89,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21599.15,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,24909.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23664.03,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,41536.8,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,24909.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32382.36,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,24909.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,41536.8,
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12689.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12689.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12689.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16496.95,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8016.36,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13197.56,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8337.02,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,12689.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12055.46,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16032.73,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12689.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16496.95,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12689.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16496.95,
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9531.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9531.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9531.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12391.55,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6165.83,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9913.24,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6412.46,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,9531.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9055.36,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12331.65,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9531.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12391.55,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9531.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12391.55,
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,25643.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25643.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25643.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33336.91,130,MS-DRG,,Case rate,130% Medicare MS-DRG,15760.14,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26669.53,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16390.56,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,25643.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24361.59,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,31520.29,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,25643.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33336.91,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,25643.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,33336.91,
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14743.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14743.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14743.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19166.39,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10261.84,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15333.12,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10672.32,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,14743.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14006.21,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,20523.68,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14743.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19166.39,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14743.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20523.68,
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9436.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9436.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9436.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12267.58,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6028.93,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9814.06,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6270.09,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,9436.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8964.77,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12057.86,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9436.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12267.58,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9436.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12267.58,
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,23489.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23489.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23489.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30536.29,130,MS-DRG,,Case rate,130% Medicare MS-DRG,15085.35,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24429.03,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15688.77,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,23489.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22314.98,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,30170.7,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,23489.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30536.29,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,23489.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,30536.29,
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13290.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13290.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13290.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17277.96,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6934.51,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13822.37,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7211.9,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,13290.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12626.2,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13869.02,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13290.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17277.96,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13290.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17277.96,
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8745.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8745.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8745.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11368.83,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4672.07,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9095.06,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4858.96,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,8745.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8307.99,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9344.15,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8745.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11368.83,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8745.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11368.83,
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14699.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14699.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14699.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19109.57,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8330.14,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15287.66,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8663.35,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,14699.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13964.69,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16660.27,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14699.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19109.57,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14699.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,19109.57,
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8545.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8545.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8545.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11109.54,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7258.58,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8887.63,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7548.93,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,8545.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8118.51,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14517.16,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8545.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11109.54,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8545.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,14517.16,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,30482.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30482.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30482.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39627.24,130,MS-DRG,,Case rate,130% Medicare MS-DRG,16090.27,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31701.79,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16733.89,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,30482.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28958.37,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,32180.54,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,30482.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39627.24,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,30482.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,39627.24,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,20026.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20026.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20026.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26034.19,130,MS-DRG,,Case rate,130% Medicare MS-DRG,15503.31,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20827.35,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16123.45,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,20026.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19024.99,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,31006.62,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,20026.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26034.19,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20026.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,31006.62,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13703.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13703.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13703.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17814.1,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7920.66,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14251.28,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8237.49,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,13703.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13017.99,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,15841.31,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13703.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17814.1,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13703.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17814.1,
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13022.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13022.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13022.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16928.77,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8026.06,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13543.02,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8347.1,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,13022.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12371.02,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16052.11,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13022.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16928.77,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13022.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16928.77,
RENAL FAILURE WITH CC,683,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8254.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8254.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8254.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10730.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5660.03,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8584.32,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5886.44,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8254.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7841.44,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11320.07,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8254.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10730.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8254.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11320.07,
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,5931.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5931.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5931.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7710.74,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3509.05,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6168.59,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3649.42,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,5931.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5634.77,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7018.1,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,5931.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7710.74,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5931.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,7710.74,
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15712.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15712.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15712.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20426.72,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6292.43,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16341.37,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6544.13,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,15712.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14927.22,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12584.85,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15712.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20426.72,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15712.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20426.72,
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9402.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9402.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9402.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12223.17,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4894.38,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9778.54,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5090.16,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9402.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8932.32,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9788.76,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9402.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12223.17,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9402.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12223.17,
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7301.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7301.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7301.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9491.76,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3184.98,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7593.4,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3312.38,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7301.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6936.28,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,6369.96,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7301.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9491.76,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7301.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9491.76,
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10428.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10428.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10428.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13556.86,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6675.25,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10845.48,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6942.27,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,10428.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9906.93,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13350.51,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10428.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13556.86,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10428.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13556.86,
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7507.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7507.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7507.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9760.35,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4729.01,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7808.28,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4918.18,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7507.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7132.56,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9458.02,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7507.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9760.35,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7507.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9760.35,
URINARY STONES WITH MCC,693,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12350.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12350.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12350.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16055.83,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5791.48,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12844.67,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6023.14,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,12350.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11733.11,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11582.96,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12350.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16055.83,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12350.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16055.83,
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7315.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7315.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7315.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9510.35,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4443.71,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7608.28,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4621.46,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7315.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6949.87,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8887.42,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7315.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9510.35,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7315.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9510.35,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10599.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10599.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10599.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13779.99,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5842.97,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11023.99,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6076.69,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,10599.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10069.99,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11685.94,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10599.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13779.99,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10599.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13779.99,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6595.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6595.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6595.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8574.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3148.03,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6859.52,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3273.95,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6595.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6265.91,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,6296.06,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6595.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8574.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6595.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,8574.4,
URETHRAL STRICTURE,697,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9941.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9941.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9941.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12923.59,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3685.32,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10338.87,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3832.74,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9941.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9444.16,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7370.64,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9941.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12923.59,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9941.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12923.59,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14242.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14242.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14242.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18515.55,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8380.41,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14812.44,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8715.63,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,14242.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13530.59,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16760.83,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14242.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18515.55,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14242.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18515.55,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9207.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9207.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9207.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11970.08,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5961.09,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9576.06,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6199.53,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9207.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8747.36,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11922.17,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9207.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11970.08,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9207.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11970.08,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6724.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6724.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6724.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8741.75,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4217.16,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6993.4,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4385.85,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6724.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6388.2,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8434.32,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6724.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8741.75,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6724.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,8741.75,
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,16686.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16686.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16686.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21692.23,130,MS-DRG,,Case rate,130% Medicare MS-DRG,11503,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17353.78,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11963.13,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,16686.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15852.01,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,23006.01,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,16686.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21692.23,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16686.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,23006.01,
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12685.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12685.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12685.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16491.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6981.76,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13193.43,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7261.03,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,12685.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12051.69,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13963.52,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12685.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16491.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12685.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16491.79,
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,18346.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18346.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18346.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23850.29,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9140.01,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19080.24,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9505.62,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,18346.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17429.06,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,18280.02,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,18346.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23850.29,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18346.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,23850.29,
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11405,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11405,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11405,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14826.5,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5830.25,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11861.2,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6063.46,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,11405,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10834.75,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11660.5,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11405,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14826.5,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11405,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,14826.5,
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,17965.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17965.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17965.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23355.45,130,MS-DRG,,Case rate,130% Medicare MS-DRG,11282.51,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18684.36,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11733.82,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,17965.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17067.44,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,22565.03,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,17965.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23355.45,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17965.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,23355.45,
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10539.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10539.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10539.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13701.48,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6561.38,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10961.18,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6823.84,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,10539.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10012.62,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13122.75,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10539.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13701.48,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10539.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13701.48,
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12624.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12624.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12624.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16411.21,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8169.01,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13128.97,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8495.78,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,12624.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11992.81,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16338.02,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12624.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16411.21,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12624.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16411.21,
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8712.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8712.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8712.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11326.46,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4779.89,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9061.17,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4971.09,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,8712.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8277.03,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9559.79,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8712.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11326.46,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8712.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11326.46,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,18638.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18638.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18638.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24229.44,130,MS-DRG,,Case rate,130% Medicare MS-DRG,14832.76,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19383.55,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15426.08,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,18638.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17706.13,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,29665.51,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,18638.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24229.44,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18638.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,29665.51,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12397.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12397.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12397.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16116.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,13423.8,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12893.43,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13960.77,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,12397.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11777.65,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,26847.61,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12397.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16116.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12397.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,26847.61,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15508.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15508.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15508.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20161.22,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9174.54,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16128.98,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9541.53,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,15508.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14733.2,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,18349.08,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15508.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20161.22,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15508.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20161.22,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10439.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10439.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10439.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13571.31,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8497.93,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10857.05,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8837.85,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,10439.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9917.5,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16995.85,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10439.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13571.31,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10439.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16995.85,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15994.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15994.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15994.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20792.42,130,MS-DRG,,Case rate,130% Medicare MS-DRG,11840.4,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16633.94,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12314.02,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,15994.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15194.46,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,23680.8,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15994.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20792.42,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15994.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,23680.8,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9950.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9950.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9950.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12935.98,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4947.68,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10348.78,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5145.59,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9950.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9453.21,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9895.37,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9950.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12935.98,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9950.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12935.98,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7528.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7528.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7528.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9787.19,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4947.68,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7829.75,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5145.59,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7528.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7152.18,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9895.37,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7528.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9787.19,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7528.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9895.37,
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10956.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10956.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10956.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14243.84,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4814.42,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11395.07,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5007,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,10956.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10408.96,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9628.84,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10956.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14243.84,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10956.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,14243.84,
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6904.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6904.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6904.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8975.21,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3455.14,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7180.17,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3593.35,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6904.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6558.81,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,6910.28,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6904.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8975.21,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6904.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,8975.21,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13977.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13977.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13977.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18170.5,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5608.55,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14536.4,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5832.89,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,13977.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13278.44,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11217.09,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13977.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18170.5,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13977.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18170.5,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7453.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7453.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7453.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9690.08,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5040.97,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7752.07,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5242.61,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7453.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7081.21,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10081.94,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7453.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9690.08,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7453.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10081.94,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9073.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9073.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9073.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11795.49,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5237.83,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9436.39,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5447.35,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9073.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8619.78,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10475.67,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9073.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11795.49,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9073.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11795.49,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6035.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6035.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6035.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7846.09,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3280.08,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6276.87,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3411.29,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6035.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5733.68,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,6560.16,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6035.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7846.09,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6035.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,7846.09,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,18368.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18368.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18368.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23879.23,130,MS-DRG,,Case rate,130% Medicare MS-DRG,11538.14,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19103.39,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11999.67,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,18368.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17450.21,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,23076.27,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,18368.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23879.23,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18368.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,23879.23,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11110.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11110.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11110.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14443.21,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7637.17,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11554.57,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7942.66,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,11110.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10554.65,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,15274.34,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11110.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14443.21,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11110.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15274.34,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,31985.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31985.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31985.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41581.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,17258.74,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33265.43,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17949.11,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,31985.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30386.69,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,34517.49,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,31985.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41581.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,31985.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,41581.79,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,16780.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16780.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16780.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21815.16,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9670.03,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17452.13,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10056.84,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,16780.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15941.85,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,19340.07,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,16780.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21815.16,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16780.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,21815.16,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11939.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11939.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11939.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15521.74,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7279.18,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12417.39,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7570.35,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,11939.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11342.81,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14558.36,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11939.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15521.74,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11939.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15521.74,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,29833.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29833.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29833.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38783.23,130,MS-DRG,,Case rate,130% Medicare MS-DRG,15525.72,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31026.58,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16146.76,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,29833.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28341.59,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,31051.44,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,29833.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38783.23,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,29833.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,38783.23,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15296.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15296.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15296.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19885.39,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10874.85,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15908.31,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11309.85,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,15296.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14531.63,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,21749.7,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15296.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19885.39,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15296.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,21749.7,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11420.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11420.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11420.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14847.16,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5901.12,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11877.73,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6137.17,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,11420.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10849.85,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11802.24,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11420.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14847.16,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11420.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,14847.16,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15255.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15255.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15255.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19832.71,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7114.42,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15866.17,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7399,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,15255.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14493.13,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14228.83,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15255.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19832.71,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15255.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,19832.71,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10329.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10329.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10329.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13428.75,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5372.31,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10743,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5587.2,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,10329.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9813.32,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10744.62,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10329.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13428.75,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10329.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13428.75,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,16054.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16054.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16054.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20870.94,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7225.27,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16696.75,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7514.28,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,16054.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15251.84,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14450.53,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,16054.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20870.94,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16054.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20870.94,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9327.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9327.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9327.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12126.06,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4635.73,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9700.85,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4821.16,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,9327.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8861.35,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9271.46,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9327.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12126.06,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9327.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12126.06,
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14415.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14415.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14415.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18739.72,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6916.34,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14991.78,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7193,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,14415.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13694.41,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13832.68,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14415.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18739.72,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14415.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18739.72,
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8146.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8146.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8146.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10589.89,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5123.35,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8471.91,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5328.29,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,8146.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7738.77,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10246.7,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8146.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10589.89,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8146.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10589.89,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12260.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12260.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12260.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15938.07,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5555.24,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12750.45,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5777.45,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,12260.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11647.05,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11110.48,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12260.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15938.07,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12260.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15938.07,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,21099.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21099.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21099.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27428.83,130,MS-DRG,,Case rate,130% Medicare MS-DRG,12037.27,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21943.06,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12518.76,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,21099.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20044.15,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,24074.53,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,21099.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27428.83,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21099.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,27428.83,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11903.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11903.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11903.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15474.23,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6515.34,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12379.38,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6775.96,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,11903.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11308.09,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13030.68,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11903.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15474.23,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11903.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15474.23,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15816.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15816.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15816.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20562.05,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7780.73,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16449.64,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8091.96,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,15816.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15026.11,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,15561.46,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15816.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20562.05,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15816.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20562.05,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9715.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9715.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9715.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12630.19,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7024.77,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10104.15,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7305.76,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9715.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9229.75,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14049.53,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9715.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12630.19,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9715.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,14049.53,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8960.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8960.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8960.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11648.78,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4331.04,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9319.02,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4504.29,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8960.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8512.57,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8662.08,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8960.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11648.78,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8960.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11648.78,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12949.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12949.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12949.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16833.71,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6044.68,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13466.97,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6286.47,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,12949.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12301.56,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12089.36,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12949.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16833.71,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12949.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16833.71,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8983.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8983.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8983.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11678.75,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4884.69,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9343,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5080.08,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8983.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8534.47,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9769.37,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8983.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11678.75,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8983.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11678.75,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6230.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6230.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6230.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8100.21,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3716.82,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6480.17,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3865.5,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6230.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5919.38,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7433.64,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6230.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8100.21,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6230.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,8100.21,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9005.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9005.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9005.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11707.67,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4459.46,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9366.14,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4637.84,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9005.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8555.61,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8918.92,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9005.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11707.67,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9005.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11707.67,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,5908.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5908.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5908.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7680.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3473.31,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6144.63,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3612.25,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,5908.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5612.89,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,6946.63,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,5908.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7680.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5908.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,7680.79,
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10775.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10775.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10775.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2579,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4951.92,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11206.63,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5150,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,3000,100,,,Per diem,Pays based on per day rate,10775.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10236.83,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9903.85,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10775.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2579,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10775.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11206.63,
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13364.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13364.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13364.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17374.02,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7875.23,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13899.22,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8190.24,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,13364.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12696.4,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,15750.45,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13364.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17374.02,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13364.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17374.02,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7442.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7442.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7442.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9675.63,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3924.59,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7740.5,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4081.58,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,7442.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7070.65,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7849.18,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7442.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9675.63,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7442.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9675.63,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6791.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6791.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6791.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8828.52,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3928.83,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7062.82,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4085.99,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6791.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6451.61,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7857.66,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6791.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8828.52,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6791.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,8828.52,
ABORTION WITHOUT D&C,779,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8956.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8956.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8956.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11643.61,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3252.82,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9314.88,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3382.94,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8956.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8508.79,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,6505.65,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8956.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11643.61,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8956.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11643.61,
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15175.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15175.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15175.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5616,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15782.7,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4800,100,,,Per diem,Pays based on per day rate,15175.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14416.89,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,15175.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5616,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15175.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15782.7,
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9233.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9233.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9233.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5616,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9603.33,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4800,100,,,Per diem,Pays based on per day rate,9233.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8772.27,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,9233.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5616,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9233.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9603.33,
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7979.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7979.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7979.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5616,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8299.19,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4800,100,,,Per diem,Pays based on per day rate,7979.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7580.99,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,7979.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5616,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7979.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,8299.19,
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14998.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14998.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14998.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5616,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15598.39,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4800,100,,,Per diem,Pays based on per day rate,14998.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14248.53,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,14998.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5616,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14998.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15598.39,
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9448.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9448.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9448.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5616,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4323.17,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9826.47,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4496.1,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,4800,100,,,Per diem,Pays based on per day rate,9448.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8976.1,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8646.33,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9448.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5616,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9448.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9826.47,
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7890.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7890.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7890.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5616,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4696.91,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8205.8,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4884.79,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,4800,100,,,Per diem,Pays based on per day rate,7890.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7495.68,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9393.82,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7890.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5616,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7890.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9393.82,
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15553.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15553.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15553.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20220.11,130,MS-DRG,,Case rate,130% Medicare MS-DRG,12116.01,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16176.09,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12600.66,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,15553.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14776.23,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,24232.02,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15553.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20220.11,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15553.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,24232.02,
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,48776.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,48776.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,48776.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,63409.39,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4321.95,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50727.51,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4494.84,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,48776.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46337.63,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8643.91,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,48776.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,63409.39,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,48776.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,63409.39,
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,33658.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33658.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33658.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43756.39,130,MS-DRG,,Case rate,130% Medicare MS-DRG,2273.95,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35005.11,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2364.91,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,33658.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31975.82,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,4547.9,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,33658.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43756.39,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,33658.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,43756.39,
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,20743.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20743.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20743.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26967.06,130,MS-DRG,,Case rate,130% Medicare MS-DRG,1714.85,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21573.65,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1783.45,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,20743.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19706.7,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,3429.7,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,20743.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26967.06,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20743.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,26967.06,
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,34545.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34545.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34545.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,44909.28,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10589.55,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35927.42,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11013.14,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,34545.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32818.32,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,21179.09,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,34545.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,44909.28,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,34545.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,44909.28,
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12935.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12935.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12935.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16816.16,130,MS-DRG,,Case rate,130% Medicare MS-DRG,25895.99,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13452.93,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,26931.85,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,12935.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12288.73,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,51791.98,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12935.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16816.16,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12935.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,51791.98,
NORMAL NEWBORN,795,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,2698.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2698.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2698.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,3508.25,130,MS-DRG,,Case rate,130% Medicare MS-DRG,1322.33,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2806.6,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1375.22,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,2698.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2563.72,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,2644.66,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,2698.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,3508.25,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2698.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,3508.25,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12367.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12367.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12367.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2579,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6378.44,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12862.01,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6633.58,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,3000,100,,,Per diem,Pays based on per day rate,12367.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11748.95,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12756.88,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12367.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2579,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12367.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12862.01,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9009.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9009.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9009.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2579,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6378.44,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9370.26,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6633.58,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,3000,100,,,Per diem,Pays based on per day rate,9009.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8559.38,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12756.88,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9009.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2579,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9009.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12756.88,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7732.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7732.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7732.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2579,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8041.33,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,100,,,Per diem,Pays based on per day rate,7732.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7345.45,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,7732.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2579,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7732.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,8041.33,
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,40468.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40468.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40468.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52608.71,130,MS-DRG,,Case rate,130% Medicare MS-DRG,17361.11,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42086.97,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18055.57,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,40468.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38444.83,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,34722.23,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,40468.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52608.71,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,40468.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,52608.71,
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,23487.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23487.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23487.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30533.18,130,MS-DRG,,Case rate,130% Medicare MS-DRG,12951.93,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24426.54,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13470.02,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,23487.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22312.71,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,25903.87,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,23487.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30533.18,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,23487.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,30533.18,
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15317.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15317.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15317.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19913.28,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8511.86,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15930.63,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8852.34,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,15317.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14552.01,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,17023.72,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15317.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19913.28,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15317.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,19913.28,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,28359.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28359.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28359.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36866.88,130,MS-DRG,,Case rate,130% Medicare MS-DRG,16751.13,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29493.51,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17421.19,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,28359.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26941.18,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,33502.27,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,28359.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36866.88,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,28359.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,36866.88,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15862.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15862.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15862.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20620.93,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8079.36,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16496.74,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8402.54,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,15862.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15069.14,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16158.72,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15862.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20620.93,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15862.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20620.93,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10714.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10714.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10714.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13928.76,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6649.21,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11143.01,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6915.18,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,10714.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10178.71,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13298.42,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10714.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13928.76,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10714.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13928.76,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9107.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9107.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9107.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2579,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9471.91,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,100,,,Per diem,Pays based on per day rate,9107.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8652.23,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,9107.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2579,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9107.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9471.91,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7029.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7029.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7029.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2579,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7310.75,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,100,,,Per diem,Pays based on per day rate,7029.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6678.09,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,7029.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2579,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7029.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,7310.75,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6295.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6295.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6295.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2579,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6547.11,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,100,,,Per diem,Pays based on per day rate,6295.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5980.54,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,6295.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2579,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6295.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,6547.11,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,18499.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18499.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18499.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24049.68,130,MS-DRG,,Case rate,130% Medicare MS-DRG,17379.29,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19239.74,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18074.47,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,18499.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17574.76,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,34758.57,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,18499.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24049.68,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18499.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,34758.57,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10666.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10666.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10666.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13866.78,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8222.92,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11093.42,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8551.84,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,10666.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10133.41,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16445.84,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10666.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13866.78,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10666.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16445.84,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9078.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9078.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9078.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11801.67,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4186.87,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9441.34,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4354.35,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9078.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8624.3,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8373.75,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9078.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11801.67,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9078.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11801.67,
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12249.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12249.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12249.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15924.64,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9077.01,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12739.71,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9440.1,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,12249.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11637.23,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,18154.03,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12249.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15924.64,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12249.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18154.03,
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8253.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8253.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8253.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10729.37,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5142.13,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8583.49,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5347.82,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8253.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7840.69,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10284.25,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8253.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10729.37,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8253.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10729.37,
COAGULATION DISORDERS,813,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13492.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13492.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13492.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17540.33,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7394.87,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14032.26,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7690.67,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,13492.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12817.93,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14789.75,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13492.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17540.33,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13492.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17540.33,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,18007.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18007.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18007.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23409.17,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6812.15,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18727.33,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7084.64,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,18007.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17106.7,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13624.3,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,18007.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23409.17,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18007.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,23409.17,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8996.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8996.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8996.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11695.27,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5342.63,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9356.21,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5556.34,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8996.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8546.54,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10685.25,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8996.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11695.27,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8996.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11695.27,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6739.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6739.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6739.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8761.36,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3512.08,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7009.09,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3652.57,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6739.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6402.53,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7024.16,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6739.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8761.36,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6739.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,8761.36,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,23479.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23479.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23479.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30523.88,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24419.11,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,23479.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22305.91,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,23479.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30523.88,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,23479.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,30523.88,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12468.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12468.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12468.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16208.73,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12966.98,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,12468.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11844.84,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,12468.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16208.73,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12468.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16208.73,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10796.5,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8637.2,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,8305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7889.75,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,8305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10796.5,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10796.5,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,49146.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49146.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49146.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,63890.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,28559.43,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51112.63,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,29701.83,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,49146.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46689.42,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,57118.86,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,49146.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,63890.79,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,49146.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,63890.79,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,18833.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18833.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18833.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24483.56,130,MS-DRG,,Case rate,130% Medicare MS-DRG,12060.89,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19586.85,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12543.33,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,18833.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17891.83,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,24121.78,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,18833.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24483.56,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18833.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,24483.56,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10940.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10940.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10940.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14222.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6830.32,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11377.71,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7103.54,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,10940.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10393.1,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13660.65,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10940.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14222.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10940.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,14222.14,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,36870.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36870.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36870.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47932.04,130,MS-DRG,,Case rate,130% Medicare MS-DRG,22545.64,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38345.63,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,23447.48,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,36870.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35027.26,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,45091.29,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,36870.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47932.04,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,36870.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,47932.04,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,18839.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18839.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18839.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24491.82,130,MS-DRG,,Case rate,130% Medicare MS-DRG,12160.23,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19593.45,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12646.65,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,18839.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17897.87,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,24320.46,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,18839.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24491.82,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18839.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,24491.82,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11358.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11358.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11358.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14765.54,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7969.12,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11812.43,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8287.89,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,11358.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10790.2,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,15938.23,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11358.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14765.54,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11358.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15938.23,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,37870.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37870.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37870.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49231.64,130,MS-DRG,,Case rate,130% Medicare MS-DRG,23877.67,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39385.31,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,24832.79,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,37870.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35976.97,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,47755.33,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,37870.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49231.64,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,37870.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,49231.64,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,19509.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19509.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19509.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25362.69,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10630.74,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20290.15,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11055.97,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,19509.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18534.27,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,21261.47,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,19509.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25362.69,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,19509.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,25362.69,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14131.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14131.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14131.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18370.92,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7661.4,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14696.74,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7967.86,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,14131.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13424.91,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,15322.8,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14131.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18370.92,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14131.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18370.92,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,26157.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26157.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26157.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34005.3,130,MS-DRG,,Case rate,130% Medicare MS-DRG,13957.46,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27204.24,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14515.77,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,26157.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24850.02,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,27914.92,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,26157.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34005.3,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,26157.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,34005.3,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13661.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13661.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13661.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17759.35,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5787.85,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14207.48,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6019.36,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,13661.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12977.99,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11575.69,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13661.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17759.35,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13661.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17759.35,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9640.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9640.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9640.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12533.08,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10026.46,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9640.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9158.79,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,9640.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12533.08,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9640.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12533.08,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6958.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6958.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6958.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9045.47,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7236.37,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6958.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6610.15,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,6958.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9045.47,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6958.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9045.47,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,5162.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5162.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5162.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6711.78,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5369.43,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,5162.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4904.76,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,5162.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6711.78,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5162.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,6711.78,
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH MCC,834,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,45589.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,45589.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,45589.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,59265.78,130,MS-DRG,,Case rate,130% Medicare MS-DRG,49931.75,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47412.62,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,51929.06,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,45589.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43309.61,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,99863.51,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,45589.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,59265.78,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,45589.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,99863.51,
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,835,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,18860.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18860.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18860.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24518.68,130,MS-DRG,,Case rate,130% Medicare MS-DRG,14330.6,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19614.94,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14903.83,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,18860.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17917.49,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,28661.19,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,18860.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24518.68,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18860.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,28661.19,
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,836,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12315.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12315.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12315.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16010.38,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5801.78,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12808.31,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6033.85,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,12315.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11699.9,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11603.56,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12315.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16010.38,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12315.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16010.38,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,39589.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39589.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39589.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,51466.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,28332.28,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41172.91,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,29465.59,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,39589.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37609.87,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,56664.55,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,39589.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,51466.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,39589.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,56664.55,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,17002.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17002.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17002.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22103.38,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8951.63,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17682.7,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9309.7,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,17002.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16152.47,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,17903.25,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,17002.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22103.38,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17002.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,22103.38,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11451.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11451.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11451.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14886.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6084.05,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11909.12,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6327.42,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,11451.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10878.53,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12168.11,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11451.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14886.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11451.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,14886.4,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,25930.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25930.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25930.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33709.86,130,MS-DRG,,Case rate,130% Medicare MS-DRG,25200,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26967.89,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,26208.01,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,25930.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24634.13,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,50399.99,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,25930.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33709.86,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,25930.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,50399.99,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13599.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13599.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13599.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17679.81,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8609.38,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14143.84,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8953.76,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,13599.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12919.86,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,17218.77,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13599.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17679.81,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13599.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17679.81,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9570.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9570.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9570.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12441.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6892.11,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9952.91,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7167.8,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9570.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9091.6,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13784.22,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9570.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12441.14,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9570.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13784.22,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15881.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15881.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15881.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20645.73,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7681.39,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16516.58,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7988.65,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,15881.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15087.26,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,15362.78,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15881.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20645.73,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15881.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20645.73,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10291.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10291.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10291.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13379.16,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5193.61,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10703.33,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5401.36,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,10291.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9777.08,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10387.23,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10291.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13379.16,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10291.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13379.16,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7968.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7968.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7968.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10359.52,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4373.44,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8287.61,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4548.38,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7968.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7570.42,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8746.89,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7968.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10359.52,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7968.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10359.52,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,20517.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20517.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20517.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26672.62,130,MS-DRG,,Case rate,130% Medicare MS-DRG,13291.15,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21338.1,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13822.8,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,20517.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19491.53,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,26582.29,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,20517.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26672.62,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20517.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,26672.62,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10731.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10731.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10731.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13951.48,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7466.96,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11161.19,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7765.64,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,10731.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10195.31,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14933.91,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10731.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13951.48,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10731.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,14933.91,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7740.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7740.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7740.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10063.03,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3732.57,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8050.42,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3881.88,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7740.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7353.75,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7465.14,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7740.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10063.03,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7740.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10063.03,
RADIOTHERAPY,849,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,22483.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22483.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22483.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29228.42,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5234.81,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23382.74,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5444.2,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,22483.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21359.23,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10469.61,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,22483.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29228.42,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22483.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,29228.42,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,40823.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40823.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40823.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,53070.5,130,MS-DRG,,Case rate,130% Medicare MS-DRG,33925.68,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42456.4,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,35282.73,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,40823.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38782.29,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,67851.36,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,40823.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,53070.5,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,40823.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,67851.36,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,17292.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17292.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17292.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22480.46,130,MS-DRG,,Case rate,130% Medicare MS-DRG,14030.76,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17984.37,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14592,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,17292.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16428.03,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,28061.51,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,17292.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22480.46,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17292.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,28061.51,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14619.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14619.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14619.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19005.23,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8851.68,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15204.19,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9205.75,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,14619.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13888.44,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,17703.36,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14619.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19005.23,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14619.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,19005.23,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,36286.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36286.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36286.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47172.72,130,MS-DRG,,Case rate,130% Medicare MS-DRG,24301.68,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37738.18,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,25273.77,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,36286.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34472.37,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,48603.37,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,36286.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47172.72,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,36286.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,48603.37,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,18067.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18067.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18067.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23487.69,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10813.67,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18790.15,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11246.22,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,18067.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17164.08,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,21627.34,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,18067.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23487.69,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18067.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,23487.69,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11294.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11294.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11294.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14682.89,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9474.38,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11746.31,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9853.36,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,11294.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10729.8,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,18948.76,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11294.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14682.89,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11294.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18948.76,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15733.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15733.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15733.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20453.56,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9513.75,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16362.85,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9894.31,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,15733.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14946.83,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,19027.5,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15733.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20453.56,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15733.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20453.56,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9086.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9086.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9086.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11812.01,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5219.66,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9449.61,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5428.45,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9086.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8631.85,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10439.32,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9086.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11812.01,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9086.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11812.01,
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8111.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8111.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8111.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10544.44,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4892.56,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8435.55,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5088.27,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8111.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7705.55,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9785.12,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8111.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10544.44,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8111.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10544.44,
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14127.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14127.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14127.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18365.76,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4752.64,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14692.61,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4942.74,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,14127.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13421.13,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9505.27,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14127.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18365.76,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14127.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18365.76,
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8388.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8388.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8388.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10904.97,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4355.27,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8723.98,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4529.48,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8388.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7969.02,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8710.54,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8388.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10904.97,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8388.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10904.97,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,17722.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17722.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17722.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23039.34,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10725.23,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18431.47,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11154.25,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,17722.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16836.44,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,21450.46,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,17722.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23039.34,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17722.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,23039.34,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9721.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9721.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9721.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12638.46,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4699.33,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10110.77,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4887.31,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9721.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9235.8,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9398.66,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9721.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12638.46,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9721.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12638.46,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6584.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6584.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6584.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8559.92,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4699.33,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6847.93,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4887.31,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6584.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6255.32,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9398.66,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6584.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8559.92,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6584.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9398.66,
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,56443.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,56443.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,56443.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,73376.37,130,MS-DRG,,Case rate,130% Medicare MS-DRG,36212.35,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58701.09,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,37660.87,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,56443.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,53621.19,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,72424.7,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,56443.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,73376.37,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,56443.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,73376.37,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,7,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,98572.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,98572.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,98572.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,128144.24,130,MS-DRG,,Case rate,130% Medicare MS-DRG,60493.44,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102515.39,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,62913.21,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,98572.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,93643.87,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,120986.87,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,98572.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,128144.24,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,98572.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,128144.24,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9280.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9280.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9280.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12064.07,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6029.54,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9651.25,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6270.72,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9280.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8816.05,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12059.07,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9280.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12064.07,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9280.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12064.07,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,30748.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30748.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30748.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39973.31,130,MS-DRG,,Case rate,130% Medicare MS-DRG,11865.84,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31978.65,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12340.48,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,30748.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29211.27,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,23731.68,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,30748.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39973.31,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,30748.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,39973.31,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8681.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8681.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8681.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11286.18,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3748.32,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9028.95,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3898.25,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8681.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8247.6,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7496.64,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8681.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11286.18,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8681.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11286.18,
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8299.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8299.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8299.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10789.27,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3233.44,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8631.42,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3362.78,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8299.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7884.47,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,6466.88,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8299.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10789.27,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8299.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10789.27,
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8560.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8560.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8560.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11128.13,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3330.96,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8902.5,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3464.21,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8560.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8132.1,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,6661.93,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8560.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11128.13,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8560.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11128.13,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15998.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15998.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15998.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20798.62,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4776.26,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16638.9,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4967.31,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,15998.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15198.99,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9552.52,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15998.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20798.62,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15998.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20798.62,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15057.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15057.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15057.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19574.44,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6789.13,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15659.55,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7060.7,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,15057.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14304.4,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13578.27,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15057.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19574.44,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15057.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,19574.44,
PSYCHOSES,885,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11954.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11954.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11954.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15540.33,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4375.26,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12432.26,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4550.27,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,11954.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11356.4,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8750.52,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11954.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15540.33,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11954.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15540.33,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14459.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14459.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14459.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18797.58,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3463.02,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15038.07,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3601.54,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,14459.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13736.7,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,6926.03,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14459.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18797.58,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14459.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18797.58,
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11391.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11391.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11391.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14808.94,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3604.76,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11847.15,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3748.95,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,11391.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10821.92,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7209.52,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11391.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14808.94,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11391.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,14808.94,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,5661.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5661.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5661.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7359.51,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3498.75,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5887.61,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3638.71,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,5661.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5378.1,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,6997.51,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,5661.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7359.51,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5661.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,7359.51,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13880.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13880.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13880.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18044.47,130,MS-DRG,,Case rate,130% Medicare MS-DRG,2677.37,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14435.57,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2784.47,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,13880.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13186.34,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,5354.74,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13880.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18044.47,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13880.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18044.47,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15225.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15225.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15225.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19793.46,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8467.64,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15834.77,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8806.35,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,15225.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14464.45,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16935.28,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15225.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19793.46,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15225.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,19793.46,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7894.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7894.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7894.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10263.45,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8210.76,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7894.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7500.21,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,7894.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10263.45,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7894.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10263.45,
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,35487.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35487.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35487.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46133.48,130,MS-DRG,,Case rate,130% Medicare MS-DRG,18609.54,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36906.78,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,19353.94,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,35487.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33712.93,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,37219.09,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,35487.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46133.48,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,35487.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,46133.48,
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,16072.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16072.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16072.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20894.69,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8354.97,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16715.75,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8689.18,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,16072.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15269.2,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16709.94,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,16072.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20894.69,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16072.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20894.69,
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,10961.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10961.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10961.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14250.03,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6062.85,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11400.02,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6305.37,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,10961.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10413.48,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12125.7,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,10961.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14250.03,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10961.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,14250.03,
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,26971.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26971.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26971.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35063.17,130,MS-DRG,,Case rate,130% Medicare MS-DRG,15952.77,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28050.54,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16590.89,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,26971.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25623.09,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,31905.54,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,26971.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35063.17,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,26971.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,35063.17,
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13680.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13680.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13680.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17785.18,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8380.41,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14228.15,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8715.63,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,13680.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12996.86,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16760.83,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13680.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17785.18,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13680.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17785.18,
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,16048.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16048.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16048.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20862.67,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6374.2,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16690.14,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6629.17,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,16048.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15245.8,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12748.4,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,16048.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20862.67,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16048.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20862.67,
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,30653.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30653.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30653.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39849.34,130,MS-DRG,,Case rate,130% Medicare MS-DRG,26353.32,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31879.47,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,27407.47,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,30653.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29120.67,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,52706.65,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,30653.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39849.34,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,30653.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,52706.65,
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,17021.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17021.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17021.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22128.17,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10610.14,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17702.54,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11034.55,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,17021.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16170.59,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,21220.28,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,17021.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22128.17,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17021.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,22128.17,
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11873.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11873.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11873.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15435.99,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7427.58,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12348.79,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7724.69,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,11873.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11280.15,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14855.17,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11873.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15435.99,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11873.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15435.99,
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12972.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12972.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12972.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16863.69,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6870.91,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13490.95,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7145.75,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,12972.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12323.47,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13741.82,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12972.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16863.69,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12972.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16863.69,
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8308.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8308.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8308.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10801.69,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4183.24,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8641.35,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4350.57,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8308.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7893.54,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,8366.48,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8308.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10801.69,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8308.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10801.69,
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15193.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15193.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15193.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19751.1,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9691.84,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15800.88,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10079.52,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,15193.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14433.49,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,19383.68,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15193.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19751.1,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15193.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,19751.1,
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6331.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6331.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6331.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8230.38,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3747.71,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6584.3,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3897.62,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6331.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6014.51,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7495.43,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6331.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8230.38,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6331.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,8230.38,
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13777.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13777.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13777.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17911.21,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7644.44,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14328.96,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7950.22,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,13777.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13088.96,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,15288.88,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13777.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17911.21,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13777.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,17911.21,
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7937.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7937.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7937.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10318.2,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3985.77,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8254.56,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4145.2,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7937.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7540.23,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,7971.54,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7937.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10318.2,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7937.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10318.2,
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15596.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15596.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15596.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20274.85,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7207.7,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16219.88,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7496.01,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,15596.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14816.24,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14415.4,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15596.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20274.85,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15596.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20274.85,
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9311.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9311.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9311.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12104.37,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6652.24,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9683.49,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6918.33,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9311.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8845.5,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,13304.47,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9311.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12104.37,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9311.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,13304.47,
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6640.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6640.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6640.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8633.29,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4587.87,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6906.63,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4771.39,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6640.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6308.94,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9175.75,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6640.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8633.29,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6640.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9175.75,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14961.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14961.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14961.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19450.47,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8117.52,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15560.38,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8442.23,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,14961.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14213.81,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16235.04,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14961.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19450.47,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14961.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,19450.47,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9133.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9133.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9133.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11872.97,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4765.36,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9498.37,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4955.97,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9133.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8676.4,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9530.71,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9133.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11872.97,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9133.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11872.97,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,210558.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,210558.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,210558.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,273726.61,130,MS-DRG,,Case rate,130% Medicare MS-DRG,82137.13,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218981.29,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,85422.67,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,210558.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,200030.98,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,164274.27,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,210558.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,273726.61,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,210558.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,273726.61,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,56084.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,56084.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,56084.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,72909.45,130,MS-DRG,,Case rate,130% Medicare MS-DRG,13548.59,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58327.56,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14090.54,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,56084.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,53279.98,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,27097.17,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,56084.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,72909.45,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,56084.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,72909.45,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,26648.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26648.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26648.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34642.71,130,MS-DRG,,Case rate,130% Medicare MS-DRG,6479,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27714.17,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6738.16,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,26648.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25315.83,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,12957.99,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,26648.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34642.71,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,26648.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,34642.71,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,25190.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25190.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25190.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32747.03,130,MS-DRG,,Case rate,130% Medicare MS-DRG,22199.16,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26197.62,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,23087.14,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,25190.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23930.52,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,44398.32,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,25190.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32747.03,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,25190.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,44398.32,
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,17724.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17724.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17724.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23041.41,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5824.19,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18433.13,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6057.16,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,17724.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16837.95,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11648.38,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,17724.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23041.41,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17724.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,23041.41,
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,17315.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17315.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17315.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22510.41,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5236.62,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18008.33,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5446.09,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,17315.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16449.92,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10473.24,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,17315.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22510.41,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17315.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,22510.41,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,26646.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26646.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26646.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34640.65,130,MS-DRG,,Case rate,130% Medicare MS-DRG,16090.88,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27712.52,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16734.52,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,26646.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25314.32,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,32181.75,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,26646.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34640.65,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,26646.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,34640.65,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,18313,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18313,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18313,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23806.9,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10628.92,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19045.52,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11054.08,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,18313,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17397.35,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,21257.84,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,18313,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23806.9,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18313,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,23806.9,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,15844.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15844.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15844.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20598.2,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8039.38,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16478.56,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8360.96,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,15844.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15052.53,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16078.76,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,15844.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20598.2,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15844.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,20598.2,
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13091.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13091.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13091.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17018.64,130,MS-DRG,,Case rate,130% Medicare MS-DRG,21526.18,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13614.91,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22387.24,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,13091.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12436.7,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,43052.36,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13091.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17018.64,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13091.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,43052.36,
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9143.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9143.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9143.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11886.39,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4899.83,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9509.12,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5095.83,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9143.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8686.21,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9799.66,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9143.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11886.39,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9143.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11886.39,
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11041.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11041.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11041.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14354.38,130,MS-DRG,,Case rate,130% Medicare MS-DRG,9253.89,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11483.5,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9624.05,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,11041.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10489.74,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,18507.78,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11041.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14354.38,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11041.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18507.78,
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7461.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7461.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7461.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9699.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4983.42,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7759.52,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5182.76,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7461.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7088.03,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9966.85,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7461.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9699.4,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7461.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9966.85,
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9620.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9620.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9620.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12507.25,130,MS-DRG,,Case rate,130% Medicare MS-DRG,13337.79,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10005.8,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13871.31,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,9620.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9139.91,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,26675.58,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9620.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12507.25,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9620.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,26675.58,
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,6170.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6170.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6170.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8021.7,130,MS-DRG,,Case rate,130% Medicare MS-DRG,4658.14,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6417.36,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4844.47,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,6170.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5862.01,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,9316.28,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,6170.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8021.7,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6170.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,9316.28,
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,5784.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5784.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5784.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7519.64,130,MS-DRG,,Case rate,130% Medicare MS-DRG,3090.49,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6015.71,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3214.11,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,5784.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5495.12,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,6180.97,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,5784.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7519.64,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5784.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,7519.64,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,49492.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49492.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49492.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,64340.17,130,MS-DRG,,Case rate,130% Medicare MS-DRG,36015.48,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51472.14,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,37456.13,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,49492.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47017.82,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,72030.97,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,49492.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,64340.17,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,49492.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,72030.97,
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,31914.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31914.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31914.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41488.81,130,MS-DRG,,Case rate,130% Medicare MS-DRG,33839.06,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33191.05,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,35192.64,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,31914.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30318.75,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,67678.12,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,31914.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41488.81,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,31914.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,67678.12,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,58569.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,58569.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,58569.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,76140.86,130,MS-DRG,,Case rate,130% Medicare MS-DRG,51309.21,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60912.69,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,53361.61,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,58569.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,55641.4,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,102618.41,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,58569.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,76140.86,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,58569.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,102618.41,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,33238.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33238.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33238.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43209.91,130,MS-DRG,,Case rate,130% Medicare MS-DRG,21140.93,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34567.93,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21986.58,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,33238.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31576.47,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,42281.86,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,33238.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43209.91,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,33238.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,43209.91,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,21219.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21219.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21219.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27585.86,130,MS-DRG,,Case rate,130% Medicare MS-DRG,13021.59,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22068.69,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13542.47,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,21219.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20158.9,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,26043.19,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,21219.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27585.86,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21219.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,27585.86,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,22824.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22824.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22824.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29671.6,130,MS-DRG,,Case rate,130% Medicare MS-DRG,19688.37,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23737.28,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20475.91,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,22824.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21683.09,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,39376.73,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,22824.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29671.6,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22824.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,39376.73,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,13023.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13023.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13023.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16930.82,130,MS-DRG,,Case rate,130% Medicare MS-DRG,11026.89,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13544.66,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11467.97,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,13023.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12372.52,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,22053.78,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,13023.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16930.82,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13023.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,22053.78,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,8692.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8692.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8692.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11299.61,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5475.89,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9039.69,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5694.93,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,8692.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8257.41,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10951.78,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,8692.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11299.61,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8692.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,11299.61,
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,55709.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,55709.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,55709.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,72422.87,130,MS-DRG,,Case rate,130% Medicare MS-DRG,26066.2,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57938.3,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,27108.87,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,55709.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52924.41,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,52132.41,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,55709.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,72422.87,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,55709.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,72422.87,
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,23184.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23184.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23184.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30139.58,130,MS-DRG,,Case rate,130% Medicare MS-DRG,17520.42,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24111.66,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18221.25,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,23184.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22025.08,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,35040.85,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,23184.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30139.58,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,23184.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,35040.85,
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,24272.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24272.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24272.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31553.85,130,MS-DRG,,Case rate,130% Medicare MS-DRG,17082.47,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25243.08,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17765.78,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,24272.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23058.58,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,34164.95,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,24272.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31553.85,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,24272.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,34164.95,
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,11929.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11929.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11929.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15508.31,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7216.18,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12406.65,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7504.83,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,11929.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11333,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14432.36,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,11929.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15508.31,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11929.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,15508.31,
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,7813.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7813.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7813.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10157.04,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5308.71,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8125.63,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5521.06,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,7813.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7422.45,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,10617.41,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,7813.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10157.04,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7813.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,10617.41,
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,12349.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12349.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12349.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16053.77,130,MS-DRG,,Case rate,130% Medicare MS-DRG,7350.05,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12843.01,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7644.06,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1250,100,,,Per diem,Pays based on per day rate,12349.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11731.6,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,14700.1,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,12349.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16053.77,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12349.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,16053.77,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,38766.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38766.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38766.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,50395.88,130,MS-DRG,,Case rate,130% Medicare MS-DRG,30731.01,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40316.7,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,31960.27,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,38766.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36827.76,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,61462.01,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,38766.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,50395.88,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,38766.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,61462.01,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,20851.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20851.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20851.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27106.51,130,MS-DRG,,Case rate,130% Medicare MS-DRG,13924.15,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21685.21,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14481.12,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,20851.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19808.6,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,27848.29,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,20851.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27106.51,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20851.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,27848.29,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14090.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14090.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14090.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18317.21,130,MS-DRG,,Case rate,130% Medicare MS-DRG,8447.04,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14653.77,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8784.93,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,14090.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13385.65,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,16894.09,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14090.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18317.21,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14090.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,18317.21,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,27929.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27929.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27929.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36308,130,MS-DRG,,Case rate,130% Medicare MS-DRG,24123.6,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29046.4,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,25088.56,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,27929.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26532.77,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,48247.19,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,27929.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36308,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,27929.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,48247.19,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,14581.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14581.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14581.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18955.64,130,MS-DRG,,Case rate,130% Medicare MS-DRG,10539.88,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15164.51,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10961.48,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,14581.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13852.2,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,21079.75,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,14581.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18955.64,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14581.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,21079.75,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,9680.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9680.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9680.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12584.73,130,MS-DRG,,Case rate,130% Medicare MS-DRG,5901.12,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10067.78,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6137.17,104,CUSTOM-DRG,,Case rate,104% of GA Medicaid,,,,,Other,Not Separately reimbursable,1600,100,,,Per diem,Pays based on per day rate,9680.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9196.53,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,11802.24,100,CUSTOM-DRG,,Case rate,100% of GA Medicaid,9680.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12584.73,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9680.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,12584.73,
PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS,998,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,1095.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1095.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1095.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1424.55,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1139.64,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1095.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1041.02,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,1095.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1424.55,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1095.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,1424.55,
UNGROUPABLE,999,MS-DRG,,,,,inpatient,,,,,,950,100,,,per diem,pays based on per day rate,1095.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1095.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1095.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1424.55,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1139.64,104,MS-DRG,,Case rate,104% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1095.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1041.02,95,MS-DRG,,Case rate,95% Medicare MS-DRG,1100,100,,,Per diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,1095.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1424.55,130,MS-DRG,,Case rate,130% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1095.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,950,1424.55,